Health First Colorado (Colorado's Medicaid Program) Managed Care and CHP+.   Managed Care Provider ESCALATION REQUEST FORM
HCPF values the services you provide for Coloradans and as such, has developed a process to assist providers with concerns or issues you may be experiencing.    

This form is intended for use by providers contracted (or attempting to) contract with  Regional Accountable Entities and/or Child Health Plan Plus (CHP+) Managed Care Organizations. 

Managed Care participating providers are asked to contact the MCE(s) they are directly contracted with to resolve any concerns. You may find contact information for all Regional Accountable Entities and Child Health Plan Plus (CHP+) Managed Care Organizations here on the HCPF Provider Help page.

Providers not participating in the Managed Care program or providers that may have questions related to Health First Colorado (Colorado's Medicaid Program) are asked to please reach out directly to the Department's fiscal agent - Gainwell Technologies and visit the HCPF Provider Help page for further assistance. Below is a sample list of assistance you may expect receive.
  • Claims Submission and Billing Questions
  • Member Eligibility
  • Provider Medicaid Enrollment Assistance
  • Provider Web Portal Technical Support
HCPF understands that situations may arise where escalating provider concerns may be necessary after having exhausted collaborative efforts with the MCEs.  This escalation request form is intended to provide an additional level of communication to support Providers, as circumstances may dictate.  

We extend our sincerest gratitude and appreciation for your continued service to Coloradans.
Sign in to Google to save your progress. Learn more
Email *
Today's date *
MM
/
DD
/
YYYY
As a provider or provider representative that is currently contracted (or attempting to contract) with a Regional Accountable Entity and/or Child Health Plan Plus (CHP+) Managed Care Organization, I attest to having contacted the MCE/MCO with my concern and requesting escalated assistance with that concern at this time. *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of State.co.us Executive Branch.

Does this form look suspicious? Report

Google Forms