Form 000001 "Refund to Health First Colorado or Returned Warrant" - Colorado

What Is Form 000001?

This is a legal form that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the Colorado Department of Health Care Policy and Financing;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form 000001 by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Download Form 000001 "Refund to Health First Colorado or Returned Warrant" - Colorado

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DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Refund to Health First Colorado or Returned Warrant
Please Note:
Claims voided on this form will not appear on the remittance advice.
Providers are strongly encouraged to submit voided claims electronically.
A check must be attached to this form and must match the payment on the Internal Control Number (ICN) listed
below.
Denied claims can be resubmitted and do not require an adjustment.
Provider Name
Street Address (Address used to Return to Provider)
City, State, Zip Code
Telephone Number
You must include a refund check or the returned warrant with this form. No exceptions.
REQUIRED INFORMATION:
**Internal Control Number (ICN) 13 digits. Do not use to adjust denied or voided claims.
*If ICN is not available the following must be submitted with form:
*Medicaid Member ID
*Billing Provider Health First Colorado ID Number
*Date of Service
Remittance Advice Date if available
Date
By (Provider Signature)
Please complete this form and mail it to:
DXC Technology
P.O. Box 30 Denver, CO 80201
For questions regarding adjusting or voiding claims, please call the Provider Services Call Center at 1-844-235-2387.
Form #000001 (REV. 08/18)
DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Refund to Health First Colorado or Returned Warrant
Please Note:
Claims voided on this form will not appear on the remittance advice.
Providers are strongly encouraged to submit voided claims electronically.
A check must be attached to this form and must match the payment on the Internal Control Number (ICN) listed
below.
Denied claims can be resubmitted and do not require an adjustment.
Provider Name
Street Address (Address used to Return to Provider)
City, State, Zip Code
Telephone Number
You must include a refund check or the returned warrant with this form. No exceptions.
REQUIRED INFORMATION:
**Internal Control Number (ICN) 13 digits. Do not use to adjust denied or voided claims.
*If ICN is not available the following must be submitted with form:
*Medicaid Member ID
*Billing Provider Health First Colorado ID Number
*Date of Service
Remittance Advice Date if available
Date
By (Provider Signature)
Please complete this form and mail it to:
DXC Technology
P.O. Box 30 Denver, CO 80201
For questions regarding adjusting or voiding claims, please call the Provider Services Call Center at 1-844-235-2387.
Form #000001 (REV. 08/18)