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Providers Enrolled in Colorado Medicaid May Need to Obtain and Use a New National Provider Identifier (NPI)

Colorado House Bill 18-1282, signed into law on April 25, 2018, included a new requirement that all Colorado Medicaid providers (except for individual clinicians) obtain and use a unique National Provider Identifier (NPI) for each site at which they deliver services and for each provider type specified. On all claims submitted to Colorado Medicaid, provider entities must use the unique NPI that identifies the site where the services were provided and the provider type rendering the services.

These new rules regarding the use of unique NPIs applied to any provider entity applying to enroll as a new provider on or after Jan. 1, 2020, but previously enrolled providers are not required to obtain and use unique NPIs until their first revalidation date after Jan. 1, 2021. As a result, some Colorado providers now working through the revalidation process with the Department of Health Care Policy & Financing (HCPF) are encountering errors in HCPF’s Provider Web Portal and finding they are unable to complete the process because they have not yet obtained a unique NPI for additional locations or service types.

Providers encountering these issues as a result of changes to HCPF’s billing and enrollment rules may be able to resolve their revalidation problems by taking the following steps:

1.   Request a new NPI for each additional location and/or provider type that is enrolled in Colorado Medicaid. Providers should have one NPI for each site at which they deliver services and for each provider type that is enrolled with Colorado Medicaid. For example, a physician practice group with two office locations should have at least two unique NPIs. A home care agency that provides both skilled and unskilled home care services should have at least two unique NPIs. If the same home care agency offers skilled and unskilled services from a parent location and from a branch location, it should have at least four unique NPIs.

Providers can apply for a new NPI through the National Plan and Provider Enumeration System (NPPES), either online through the NPPES website or by paper application. The application is relatively simple, and turnaround time for online applications is usually less than 24 hours, but it can take up to 20 days to receive the new NPI.

2.   Add the new NPI(s) to the existing Medicaid enrollment. Providers must use the Provider Maintenance function in HCPF’s Provider Web Portal to add a unique NPI to a service location or service type. HCPF has published a Provider Web Portal Quick Guide with step-by-step instructions for adding an NPI.

It may also be important to recognize that, since 2015, Colorado Medicaid regulations have required that each location at which services are provided must be separately enrolled with HCPF. If a provider with more than one location finds that only one location is enrolled, a new Provider Enrollment Application may be necessary.

3.   For providers who bill Medicare, add the new NPI(s) to the existing Medicare enrollment. Medicare-enrolled providers can update their NPI for each practice location by submitting the 855A or 855B form. The 855 form can be submitted electronically through Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) or by paper application, but in either case, Section 4 should be updated to add or change an NPI. Medicare application processing times can vary significantly, but usually applications are processed in 45 to 60 days. Updating or adding an NPI will not affect the provider’s Medicare effective date or Medicare ID and should, therefore, not cause any interruption in billing, collections, or cash flow.
4.   Update commercial payors as necessary. Some commercial payors may require notice from enrolled providers if there is a change to the provider’s NPI. Commercial payor notice requirements are usually detailed in the contract between the provider and the payor or in related Provider Manuals. 
©2021 Greenberg Traurig, LLP. All rights reserved. National Law Review, Volume XI, Number 117

About this Author

Jim Miles Health Care Lawyer Greenberg Traurig Law Firm

Jim Miles represents health care organizations, health care professionals, and private equity firms with commercial transactions, including mergers, acquisitions, equity and debt financing, joint ventures, and start-ups. He also assists with business planning and government relations. In addition, he advocates for health care providers undergoing government investigations by the Office of Inspector General, State Medicaid Fraud Control Units, and other government agencies.

Jim advises a range of health care providers, including ambulatory surgical centers, assisted living facilities...

Loreli Wright, Greenberg Traurig Law Firm, Healthcare Law Attorney, Denver

Loreli Wright focuses her practice on health care regulatory matters. She has experience advising hospitals, nursing homes, assisted living residences, ambulatory surgery centers, and practice groups on a wide range of matters. She provides counsel on fraud and abuse issues under Stark, Anti-Kickback, and False Claims statutes, as well as matters involving health facility licensing, certification, and accreditation, health plan contracting, corporate practice of medicine doctrine, and regulatory hurdles for emerging practice models such as telemedicine and concierge...