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Enrollment Types

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Download an enrollment checklist based on the Enrollment Type(s) associated with the chosen Provider Type.

Each section below represents an Enrollment Type. Not all Enrollment Types are available for all Provider Types. For example, a Pharmacy only has the option to enroll as a facility, while a Physician may enroll as either a Billing Individual, an Individual Within a Group, or an Ordering-Prescribing-Referring (OPR) Provider.

 

Before beginning an application through the Online Provider Enrollment tool, it is highly recommended to:

  • Download the appropriate Enrollment checklist (below).
  • Download (and review) the Provider Enrollment Manual, which can be found on the Provider Enrollment web page.

What is an Enrollment Type?

The Enrollment Type categorizes provider types to help identify additional enrollment requirements. (Examples of Enrollment Types are: Group, Facility, Billing Individual, Individual within a Group, Atypical, and Ordering/Prescribing/Referring)


The appropriate enrollment type will be dependent on how providers report income under a Federal Employer Identification Number (EIN) or Social Security Number (SSN). The definition of each enrollment type is shown in the Provider Enrollment Manual, which can be found on the Provider Enrollment web page.

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Enrollment Type Checklists

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Atypical

  • Administrative Services Organization(ASO)(81)
  • Behavioral Health ASO (91)
  • Behavioral Health MSO (92)
  • Behavioral Health Crisis Line (88)
  • Behavioral Health Secure Transportation (97)
  • Case Management Agencies (including Community Centered Boards (CCB) and Intensive Case Managers) (11)
  • Health Maintenance Organization (HMO) (23)
  • Home and Community-Based Service (HCBS) provider (This includes all waiver providers i.e. DD, SLS, BI, etc.) (36)
  • Regional Accountable Entity (RAE) (85)
  • Transportation (73) (Specialties 326 and 525)

HCBS

Atypical HCBS Enrollment Checklist

-- OR --

Non-HCBS

Atypical Non-HCBS Enrollment Checklist

Facility

  • Adult Mental Health Residential (96)
  • Ambulatory Surgery Center (ASC) (44)
  • Community Clinic (86)
  • Dialysis Center (33)
  • Home Health (10)
  • Hospice (50)
  • Hospital - General (01)
  • Hospital - Mental (02)
  • Independent Laboratory (12)
  • Indian Health Services - Pharmacy (62)
  • Medicare Only Providers (90)
  • Nursing Facility (20)
  • Nursing Facility - ICF/IID (21)
  • Optical Outlet(08)
  • Personal Care Agency (60)
  • Pharmacy (09)
  • Psychiatric Residential Treatment Facility (30)
  • Qualified Residential Treatment Program (68)
  • School Health Services (51)
  • Substance Use Disorder - Clinic (64)
  • Supply (14) (Specialties 481 and 482)
  • Transportation (13) (Specialties 086, 124 and 324)
  • X-Ray Facility (49)

Facility Enrollment Checklist

Group

  • Behavioral Health Crisis Services (95)
  • Behavioral Health Group (77)
  • Behavioral Therapy Clinic (83)
  • Birthing Center (58)
  • Clinic - Dental (47)
  • Clinic - Practitioner (16)
  • Community Mental Health Center (35)
  • Community Support Services Provider (89)
  • Developmental Evaluation Clinic (46)
  • Federally Qualified Health Center (FQHC) (32)
  • Indian Health Services - FQHC (61)
  • Non-Physician Practitioner - Group (25)
  • Rehabilitation Agency (48)
  • Residential Child Care Facility (52)
  • Rural Health Clinic (45)

Group Enrollment Checklist

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Individual Within a Group

  • Direct Entry or Certified Professional Midwife (69)
  • Foreign Teaching Physician (65)
  • Non-Physician Practitioner - Individual (24)
  • Pharmacist (75)
  • Physician Assistant (39)
  • School Speech Therapist (42)

Individual Within a Group Enrollment Checklist

Billing Individual

  • Chiropractor QMB  (18)
  • Supply (74) (Specialty 480)

Billing Individual Enrollment Checklist

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Billing Individual or Individual Within a Group

The Provider Types below can enroll using either the Billing Individual or Individual Within a Group Enrollment Type. For further information regarding these Enrollment Types, please review the document Billing Individual vs Individual within a Group.

  • Audiologist (19)
  • Behavioral Therapist (84)
  • Certified Registered Nurse Anesthetist (CRNA) (40)
  • Dental Hygienist (66)
  • Dental Therapist (98)
  • Dentist (04)
  • Doula (79)
  • Licensed Behavioral Health Clinician(38)
  • Licensed Psychologist(37)
  • Nurse Practitioner (41)
  • Nurse-Midwife (22)
  • Occupational Therapist (28)
  • Optometrist (07)
  • Osteopath (26)
  • Physical Therapist (17)
  • Physician (05)
  • Podiatrist (06)
  • Speech Therapist (27)

Billing Individual Enrollment Checklist

OR

Individual Within a Group Enrollment Checklist

Ordering-Prescribing-Referring (OPR)

IMPORTANT: OPR providers are only allowed to order, prescribe, or make referrals. OPR providers are not eligible to bill for services rendered.

  • Audiologist (19)
  • Certified Registered Nurse Anesthetist (CRNA) (40)
  • Dentist (04)
  • Licensed Psychologist(37)
  • Nurse Practitioner (41)
  • Nurse-Midwife (22)
  • Optometrist (07)
  • Osteopath (26)
  • Physician (05)
  • Physician Assistant (39)
  • Podiatrist (06)
  • Speech Therapist (27)

Ordering, Prescribing, Referring Enrollment Checklist

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IMPORTANT: While completing the application and if choosing the "Finish Later" option, it is important to keep track of the tracking number, password, and the TAX ID used.

The Provider Portal Enrollment Application password cannot be reset. If the password has been forgotten, the application can still be resumed by choosing Forgot Password and then answering the security questions correctly. If both the password and the security answers are forgotten, a new application needs to be started.

It is acceptable to provide a PSV (Primary Source Verification) for the required documents. Copies of documents are accepted.

The application requires a mailing address, a service address, and a billing address. This does not mean that billing will occur.

All documents must be uploaded through the "attachments" section of the online application. Note: Upload all documents with the submission of the application. The system will not hold documents when "Finish Later" is selected.

Call the Provider Services Call Center if the tracking number is lost or for assistance.