42 CFR 447 - Physician Attestation

1. PHYSICIAN INFORMATION

 
Pursuant to the Affordable Care Act and 42 CFR 447 state Medicaid agencies are required to reimburse for services provided by family practice, general internal medicine, or pediatric medicine primary care physicians at an amount equal to that paid by Medicare Part B for certain procedures considered to be primary care or vaccination administration. In order to qualify for the supplemental amount the physician rendering or supervising the service must PERSONALLY attest that they specialize in one of certain primary care specialties.

The physicians must also attest that 1) they are board certified in that specialty or sub-specialty or that 2) at least 60% of recent claims submitted by or on behalf of the physician to the state Medicaid agency were for these procedures or vaccination administration. Physicians wishing to attest to their eligibility to provide the services for which these supplemental payments are made should provide the information requested below.

Steps 1-4 must be completed in order to successfully attest. (Entries on step 5 are required only if you supervise advanced practice professionals.) Upon completion of this form, you will be transferred to the Department’s Provider Services page. A electronic mail acknowledgement of each attempt to attest will be sent to the respondent’s email address after validation of the data. These acknowledgements will typically be sent within a week after your attempt to attest.

Please print each page as you complete it for your records.

Questions regarding the rule and the information requested can be sent to:

richard.delaney@state.co.us
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Physician Name
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Colorado Medicaid Provider ID
(This is the practitioner's provider ID, not the group's. Responses without a valid Colorado Provider ID will not be processed.)
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Provider NPI
(This is the practitioner's NPI, not the group's. Responses without a valid NPI will not be processed.)
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Respondent's E-Mail Address
(This will be used to send an acknowledgement that your attestation has been received, validated and accepted. This email address must be accurate and not blocked by security or approved-sender software.)
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Five digit ZIP Code