"Supervision for Non-physician Practitioners (Registered Nurses Only)" - Colorado

Supervision for Non-physician Practitioners (Registered Nurses Only) is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on June 1, 2018;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
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Supervision for non-physician practitioners (Registered Nurses only)
Registered Nurses, by state regulation, require supervision and must complete this
form to enroll with Health First Colorado, Colorado’s Medicaid Program. Please
complete one of the sections below (A, B or C).
Benefit services by registered nurses must be provided in compliance with the following requirements:
Services must be performed under the supervision of an advanced practice nurse (APN) or physician (MD) who is
immediately available when services are provided.
Services must be ordered by the supervising APN/MD.
Claims must be submitted through the enrolled employer of the RN. Registered nurses must look to the enrolled
provider for compensation.
The supervising APN/MD National Provider Number (NPI) must appear on the claim form as the supervising
physician, the referring provider, or the billing provider.
Claims must be billed using procedure codes specifically designated for non-physician billing.
Claims must identify the registered nurse with their NPI, as the rendering provider.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A. Supervising APN/MD Identification
The registered nurse applicant must identify the Health First Colorado enrolled APN/MD(s) who will provide
supervision. The supervisor’s original signature must be included on this form. An original signature assures
that the supervisor is aware of and understands the supervisory role and requirements.
Supervising APN/MD
Supervising APN/MD Name
NPI
Supervising APN/MD’s Original Signature
1.
2.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B. Local Public Health Agency Identification
Employees of a local public health agency complete this form by checking the box to attest that
employment is with a local public health agency, indicate the agency‘s name and NPI, then sign and date
in the space indicated.
I attest that I am applying as an employee of a local public health agency.
Agency Name:
Agency NPI:
_
_
_
_
RN Applicant Name
Signature
Date
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C. Nurse Home Visitor Program Site Identification
Employees of a Nurse Home Visitor Program site providing targeted case management services complete
this form by checking the box to attest that enrollment is for the NHVP, sign and date in the space indicated.
I attest that I am applying to render targeted case management services to Medicaid members through the
Nurse Home Visitor Program.
Program Site Name:
Site NPI:
_
_
_
_
_
_
RN Applicant Name
Signature
Date
Revised: June 2018
Supervision for non-physician practitioners (Registered Nurses only)
Registered Nurses, by state regulation, require supervision and must complete this
form to enroll with Health First Colorado, Colorado’s Medicaid Program. Please
complete one of the sections below (A, B or C).
Benefit services by registered nurses must be provided in compliance with the following requirements:
Services must be performed under the supervision of an advanced practice nurse (APN) or physician (MD) who is
immediately available when services are provided.
Services must be ordered by the supervising APN/MD.
Claims must be submitted through the enrolled employer of the RN. Registered nurses must look to the enrolled
provider for compensation.
The supervising APN/MD National Provider Number (NPI) must appear on the claim form as the supervising
physician, the referring provider, or the billing provider.
Claims must be billed using procedure codes specifically designated for non-physician billing.
Claims must identify the registered nurse with their NPI, as the rendering provider.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A. Supervising APN/MD Identification
The registered nurse applicant must identify the Health First Colorado enrolled APN/MD(s) who will provide
supervision. The supervisor’s original signature must be included on this form. An original signature assures
that the supervisor is aware of and understands the supervisory role and requirements.
Supervising APN/MD
Supervising APN/MD Name
NPI
Supervising APN/MD’s Original Signature
1.
2.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
B. Local Public Health Agency Identification
Employees of a local public health agency complete this form by checking the box to attest that
employment is with a local public health agency, indicate the agency‘s name and NPI, then sign and date
in the space indicated.
I attest that I am applying as an employee of a local public health agency.
Agency Name:
Agency NPI:
_
_
_
_
RN Applicant Name
Signature
Date
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C. Nurse Home Visitor Program Site Identification
Employees of a Nurse Home Visitor Program site providing targeted case management services complete
this form by checking the box to attest that enrollment is for the NHVP, sign and date in the space indicated.
I attest that I am applying to render targeted case management services to Medicaid members through the
Nurse Home Visitor Program.
Program Site Name:
Site NPI:
_
_
_
_
_
_
RN Applicant Name
Signature
Date
Revised: June 2018