HPE Enrollment Backdate Form

The HPE Enrollment Backdate Form allows providers to request an effective enrollment date prior to the current date. It outlines the necessary information required for submission, including provider details and the reason for the request if it exceeds 120 days. This form serves as a guideline and does not guarantee approval for prior authorization backdates or claim payments. Providers need to submit the completed form to the specified address in Denver, Colorado. For additional assistance, please call Provider Services at 1-844-235-2387.