Information by Home and Community-Based Services Provided

Specialty Code: 879

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A DORA Acupuncturist license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Acupuncture services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

Specialty Code: 600

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Proof of Malpractice/Liability Insurance

Specialty Code: 601

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment

Specialty Code: 602

Additional Requirements:

• Each alternative care facility location must complete a separate application.
• ACF Training Certificate obtained by completing the ACF New Provider Training module on the Department's website.
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Assisted Living Residence License AND recommendation of approval from the Colorado Department of Public Health and Environment

Specialty Code: 603

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state presence required for out-of-state providers for installation and service.

Specialty Code: 607

Additional Requirements:

• If you are planning to include this service in your application and plan to enroll using your SSN rather than an EIN, please do not pay the application fee (you can just continue on to the next page of the application).
• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state presence required for out-of-state providers for installation and service.

Specialty Code: 609

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Must submit applicable licensure for Program Director to include Licensed Psychologist with demonstrated applicable experience, or LCSW, PT, OT, SLP, RN or Masters level Psychologist with demonstrated applicable experience. Must submit a copy of the license along with a resume, transcript and/or curriculum vitae for review.

Specialty Code: 610

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment
• Board Certified Behavioral Analyst (BCBA) Certificate must be submitted or one of the following licenses:
  • Licensed Clinical Social Worker (LCSW)
  • Certified Rehabilitation Counselor
  • Licensed Professional Counselor (LPC)
  • Licensed Clinical Psychologist
  • Licensed Marriage and Family Therapist

• A resume that demonstrates a minimum of two years of experience in providing counseling to individuals with intellectual and developmental disabilities.

Additional Requirements:

• Each service location must complete a separate application.
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Each individual providing services must possess one of the following certificates. However, only one certificate is required to be attached to the application:

• Community Work Incentives Coordinator (CWIC) from Virginia Commonwealth University
• Community Partner Work Incentives Counselor (CPWIC) from Virginia Commonwealth University
• Work Incentive Practitioner from Cornell University Institute on Employment and Disability

Specialty Code: 613

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• For both SSN and EIN enrollments a massage license through the Colorado Department of Regulatory Agencies (DORA) is required for each individual performing services. Out-of-state providers must ALSO provide a massage license from their appropriate state agency, along with their Colorado DORA license.
• Massage Therapy providers shall be in good standing with the Colorado Office of Massage Therapy Licensure.
• EIN enrollments - Home Care Agency Class A license or Hospice license is optional.
• Providers enrolling with an EIN must submit a statement on a letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation. Providers enrolling with an SSN do not need to provide an attestation.

Specialty Code: 614

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Hospice or Home Care Agency Class A License from the Colorado Department of Public Health and Environment.

Specialty Code: 615

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• One of the following licenses issued by the Colorado Department of Public Health and Environment: Home Care Agency Class A license or Hospice license.

Specialty Code: 616

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• One of the following licenses issued by the Colorado Department of Public Health and Environment:
  Home Care Agency Class A license
  OR
  Home Care Agency Class A or Class B license AND Personal Care/Homemaker Services certification from CDPHE
  OR
  Hospice license

Specialty Code: 617

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Social Worker, Licensed Psychologist, Licensed Independent Social Worker, or Music Therapist Board Certification or certification as a non-denominational/Spiritual/Bereavement Counselor/Chaplain if in-state.
• Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Social Worker, Licensed Psychologist, Licensed Independent Social Worker, or Music Therapist Board Certification OR certification as a non-denominational/Spiritual/Bereavement Counselor/Chaplain - if out-of-state.
• For each individual providing services, providers must submit a license and a resume showing individual/family grief, loss, or bereavement counseling with pediatric/adolescent experience of one year.
• EIN enrollments - Home Care Agency Class A license or Hospice license is optional
• Providers enrolling with an EIN must submit a statement on letterhead attesting that the provider will be the only person who will be providing services, and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license or certification and resume for each employee. The provider must sign either attestation. Providers enrolling with an SSN do not need to provide an attestation.

Specialty Code: 618

Additional Requirements:

• Contracted Case Management Agencies (SEPs and CCBs) still need to enroll each agency location separately (must complete a separate application) to bill for fee-for-service case management under the CHCBS Waiver
• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A Bachelor's Degree in any field;
  OR
• Resume demonstrating five (5) years of experience in the field of Long-Term Services and Supports (LTSS), which includes Developmental Disabilities;
  OR
• Some combination of education and relevant experience appropriate to the requirements of the position demonstrated on a resume. Relevant experience is defined as: a. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or non-profit administration, or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; AND completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two (2) years of required relevant experience.

This HCBS WAIVER Specialty ended November 1, 2022, and is no longer available for new enrollments or to be added with a maintenance update. Services may be provided by selecting a different CHRP specialty.

Specialty Code: 882

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• 40 hours of Crisis Prevention, De-escalation, and Intervention training for one Direct Support Professional providing services. Please attach training certificates to the enrollment application
  AND
• For the same Direct Support Professional, please attach their High School Diploma or equivalency degree to the enrollment application.
  Optional: Businesses/Entities in possession of the following credentials must submit a current license:
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care License for a Child Placement Agency from the Colorado Department of Human Services.

Specialty Code: 883

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• One of the following requirements:
  • Child Care License for a Child Placement Agency from the Colorado Department of Human Services
    OR
  • Recommendation of approval from the Colorado Department of Public Health and Environment to provide Specialty 634 Community Connector CES

Specialty Code: 884

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government-issued photo ID (i.e. Driver's License) must be attached to the application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services web page under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Foster Care certification or Kinship Foster Care Certification from a County Department or Child Placement Agency
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care license for a Child Placement Agency license from the Colorado Department Human Services
• Child Care license for Group Home or Group Center from the Colorado Department of Human Services
• Recommendation of approval from the Colorado Department of Public Health and Environment to provide specialty 674 Residential Habilitation Services IRSS/Host Home.
  • Residential Habilitation Services IRSS/Host Home providers must submit a signed attestation on letterhead that states the provider will only provide CHRP Habilitation services to members 18 and older.
• County Departments please email HCPF_CHRP@state.co.us prior to submitting an application.

Specialty Code: 741

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment to provide Specialty 670 Professional Services Hippotherapy CES/SLS

Specialty Code: 742

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment to provide Specialty 729 Professional Services Massage CES/SLS

Specialty Code: 743

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment to provide Specialty 672 Movement Therapy CES/SLS

Specialty Code: 885

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services web page under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Foster Care certification or Kinship Foster Care Certification from a County Department or Child Placement Agency
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care license for a Child Placement Agency license from the Colorado Department Human Services
• Child Care license for Group Home or Group Center from the Colorado Department of Human Services
• Recommendation of approval from the Colorado Department of Public Health and Environment to provide Specialty 676 Respite CES/SLS and a Home Care Agency Class A or Class B license – if applicable.
• County Departments please email HCPF_CHRP@state.co.us prior to submitting an application.

Specialty Code: 886

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Certification in a Wraparound Training Program
  • If a provider is in progress to obtain this certification, a signed attestation on letterhead must be submitted that states the provider is in progress to obtaining certification. Please include the Wraparound Coach’s information on the attestation.
  AND
• Bachelor's Degree in a human behavioral science or related field of study OR resume that demonstrates experience working with Long-Term Services and Supports (LTSS) populations, in a private or public social services agency may substitute for the required education on a year for year basis. When using a combination of experience and education to qualify, the education must have a strong emphasis in a human behavioral science field.
  Optional: Businesses/Entities in possession of the following credentials must submit a current license:
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care License for a Child Placement Agency from the Colorado Department of Human Services.

Specialty Code: 880

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A DORA Chiropractic license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Chiropractic services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

Special Instructions:

• CCBs don't have one 'Provider Type' or 'Specialty' assigned to them that encompasses everything they do. CCBs will need to complete a couple different applications with us, depending on the services they provide.
• One of these applications will be as the case manager Provider Type (11).
• Another application that CCBs may need to complete is as the billing agent Provider Type (53).
• If your CCB also provides any HCBS services or any other state plan services, you will need to submit an application for that as well.
• Electronic Visit Verification (EVV) is required with this enrollment and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Specialty Code: 634

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 635

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Clinical Psychologist, or Certified Rehabilitation Counselor.
• Curriculum Vitae or resume for Master's or Doctoral level counselor, outlining two years of mental health counseling experience and education.
• Providers enrolling with an EIN must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license or certification and resume for each employee. The provider must sign either attestation. Providers enrolling with an SSN do not need to provide an attestation.

Specialty Code: 639

Additional Requirements:

• Each day habilitation location needs to enroll separately (must complete a separate application).
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 713

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 641

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment.

Special Instructions:

• If you are a dental provider who provides DIDD dental services you do not need to enroll as more than one provider type. You will enroll as a dental provider and submit your claims to DentaQuest for processing for both services.

Specialty Code: 643

Additional Requirements:

• Please review this Electronic Monitoring Letter.
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state presence required for out-of-state providers for installation and service.

Specialty Code: 645

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• For EIN Enrollments, a Home Care Agency Class A license or Hospice license is optional.
• License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Social Worker (LSW), Licensed Independent Social Worker (LISW), or Licensed Psychologist (own state's license) AND resume showing one year of experience in the provision of art/play therapy to pediatric/adolescent clients OR Non-denominational/spiritual/bereavement counselor/chaplain certification AND resume showing one year of experience in the provision of art/play therapy to pediatric/adolescent clients.
• Providers enrolling with an EIN must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license or certification and resume for each employee. The provider must sign either attestation. Providers enrolling with an SSN do not need to provide an attestation.

Specialty Code: 646

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A Bachelor's, Master's, or Doctorate in Music Therapy for each individual providing services.
• Certification from the Certification Board for Music Therapists for each individual providing services.
• A resume that demonstrates at least one year of experience in the provision of music therapy to pediatric/adolescent clients for each individual providing services.
• Providers enrolling with an EIN must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current certification, degree, and resume for each employee. The provider must sign either attestation. Providers enrolling with an SSN do not need to provide an attestation.

Specialty Code: 702

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• None

Specialty Code: 648

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

A list of counties/cities served must be attached to the application. For each county/city, please attach one of the following:

• Contractor's License for counties/cities served 
  • If the Contractor's license name and address do not match the enrollment application information, please attach a signed attestation on letterhead that states the name on the Contractor's license is an employee or contractor of the enrolling provider. 
    OR
• If services do not require a Contractor's license, please attach a signed attestation on letterhead that states services provided do not require a Contractor's license
  OR
• If services are provided in a county/city that does not require a Contractor's license, please attach a signed attestation on letterhead that states the county/city served does not require a Contractor's license.

Specialty Code: 752

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of W-9 signed within last six months
  • Address must match one address listed in application
  • DBA (Trade Name) must be listed on Line 2 if included on the application
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Voided check or signed bank letter
  • Voided check and bank letter address must match an address on application
  • If bank letter is submitted, the letter must be signed by the bank in the last six months
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state providers must possess a current license to operate a retail food establishment, issued by the Colorado Department of Public Health and Environment. (Attach a copy of the current license and complete the license information.)
• Out of State providers must attach a signed attestation, on letterhead, that states the provider is enrolled in their own state's Medicaid Program as a meals provider.

Specialty Code: 651

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

A list of counties/cities served must be attached to the application. For each county/city, please attach one of the following:

• Contractor's License for counties/cities served 
  • If the Contractor's license name and address do not match the enrollment application information, please attach a signed attestation on letterhead that states the name on the Contractor's license is an employee or contractor of the enrolling provider. 
    OR
• If services do not require a Contractor's license, please attach a signed attestation on letterhead that states services provided do not require a Contractor's license
  OR
• If services are provided in a county/city that does not require a Contractor's license, please attach a signed attestation on letterhead that states the county/city served does not require a Contractor's license.

Specialty Code: 652

Additional Requirements:

• If you are planning to include this service in your application and plan to enroll using your SSN rather than an EIN, please do not pay the application fee (you can just continue on to the next page of the application).
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 656

• The IHSS agency may only serve contiguous counties disclosed on their most recent home care license renewal application.
• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Home Care Agency Class A or Class B license from the Colorado Department of Public Health and Environment
• Recommendation of approval from the Colorado Department of Public Health and Environment
• IHSS Provider Training certificate must be submitted for current and prospective In-Home Support Services (IHSS) Agencies. Training is provided through Consumer Direct for Colorado (CDCO) via hosted webinar, and is required for the agency administrators and back-up administrators annually. For more information and to register for IHSS Provider Training, please visit the CDCO website. Department contact: Emily Harvey

• Provider must also be approved for specialty 666 - Personal Care/Homemaker Services

Specialty Code: 654

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment. Must be a Home Care Agency (HCA) Class A or Class B license.
• Home Care Agency (HCA) Class A or Class B license from the Colorado Department of Public Health and Environment.

Specialty Code: 753

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Colorado Department of Public Health and Environment Home Care Agency Class A or Class B license is required only for providers interested in providing members training on Personal Care.
  OR
• A signed attestation on letterhead that states the provider is not providing members training on Personal Care.

Specialty Code: 881

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A DORA Massage Therapist license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Massage Therapist services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

• Each service location must complete a separate application.
• Copy of one of the following IRS documents.
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

• Assisted Living Residence License AND recommendation of approval from the Colorado Department of Public Health and Environment. The Recommendation of approval is not required to be attached to the application.

Specialty Code: 659

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 660

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government-issued photo ID (i.e. Driver's License) must be attached to the application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If a bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Effective March 15, 2022, an IntelliRide Transportation Certificate of Compliance must be attached to new and maintenance applications. For more information regarding non-medical transportation (NMT) instructions, please visit the Non-Medical Transportation (NMT) Benefit web page.

Specialty Code: 661

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Effective March 15, 2022, an IntelliRide Transportation Certificate of Compliance must be attached to new and maintenance applications. For more information regarding non-medical transportation (NMT) instructions, please visit the Non-Medical Transportation (NMT) Benefit web page.

Specialty Code: 662

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• None

Specialty Code: 754

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• None

Specialty Code: 664

Additional Requirements:

• If you are planning to include this service in your application and plan to enroll using your SSN rather than an EIN, please do not pay the application fee (you can just continue on to the next page of the application).
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Certification from the Colorado Department of Public Health and Environment
• Home Care Agency Class A or Class B license issued by the Colorado Department of Public Health and Environment
  OR
• If CDPHE does not require a provider to obtain a Home Care Agency license for this specialty, a signed attestation on letterhead must be submitted that states one of the following:
  • Provider is an SSN provider that only has one employee
  • Provider is an EIN provider that only has one employee who provides hands-on assistance
  • Provider is an EIN provider that does not provide hands-on assistance

Specialty Code: 666

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Recommendation of approval from the Colorado Department of Public Health and Environment.
• Home Care Agency Class A or Class B license from the Colorado Department of Public Health and Environment

Specialty Code: 668

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state presence required for out-of-state providers for installation and service.

Specialty Code: 669

Additional Requirements:

• Each Prevocational service location must complete a separate application
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 670

Additional Requirements:

• Each Hippotherapy service location must complete a separate application
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.
• Licensure to include Physical Therapist (PT), Occupational Therapist (OT), or Speech Language Pathologist (SLP), AND AHCB Hippotherapy Certification or Hippotherapy Clinical Specialist Certification for each individual providing services

Specialty Code: 672

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment
• Board Certified Music Therapist certification or Dance Therapy certification.

Specialty Code: 729

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.
• Massage Therapy License for each individual providing services

Specialty Code: 756

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program). For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• Remote Supports Training Certificate obtained by completing the Remote Supports Provider Training
• A signed attestation on letterhead that the platform used for Remote Supports is HIPAA compliant.
• Policies and Procedures regarding:
  • Ensuring member privacy and HIPAA compliance
  • Rights of Participants
  • Contingency Plan for Provision of Remote Supports if Technology fails
  • Attestation that Professionals on staff may not practice outside of their respective scope
  • Maintaining an up-to-date person-centered plan for Remotes Supports service delivery

Specialty Code: 673

Additional Requirements:

• Each group home location must complete a separate application
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.
• Community Residential Home for Persons with Developmental Disabilities License from the Colorado Department of Public Health and Environment.

Specialty Code: 674

Additional Requirements:

• Each agency will enroll separately, each host home location does not need to enroll separately.
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• As of January 1, 2020, IRSS providers must pass the Colorado Division of Housing (DOH) IRSS Inspection Protocol every two years. All Host Homes and IRSS settings that are owned or leased by a PASA must pass the inspection. Please note that Family Caregiver Settings are excluded from this requirement. To request an inspection, please email the Division of Housing at IRSS.residential.inspections@state.co.us for inspection information. This does not need to be done prior to enrollment but should be done as soon as possible to ensure your agency meets timeline requirements.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 675

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

Providers must meet one of the following sets of requirements:

• Home Class Agency Class A or Class B license AND recommendation of approval for Personal Care/Homemaker Services from the Colorado Department of Public Health and Environment.
• Assisted Living Residence license AND recommendation of approval for Alternative Care Facility from the Colorado Department of Public Health and Environment
• Long Term Care license for a Nursing Facility from the Colorado Department of Public Health and Environment

Specialty Code: 676

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Certification from the Colorado Department of Public Health and Environment
• Home Care Agency Class A or Class B license issued by the Colorado Department of Public Health and Environment
  OR
• If CDPHE does not require a provider to obtain a Home Care Agency license for this specialty, a signed attestation on letterhead must be submitted that states one of the following:
  • Provider is an SSN provider that only has one employee
  • Provider is an EIN provider that only has one employee who provides hands-on assistance
  • Provider is an EIN provider that does not provide hands-on assistance

Specialty Code: 677

Additional Requirements:

• If you are planning to include this service in your application and plan to enroll using your SSN rather than an EIN, please do not pay the application fee (you can just continue on to the next page of the application).
• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• In-state presence required for out-of-state providers for installation and service.

Specialty Code: 678

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Certified Addiction Counselor II or Psychologist License from the Colorado Department of Regulatory Agencies (DORA).
• Providers enrolling with an EIN must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation. Sole proprietors enrolling with an SSN do not need to provide an attestation.

Specialty Code: 679

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment.

Specialty Code: 680

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Assisted Living Residence License or Home Care Agency Class A AND recommendation of approval from the Colorado Department of Public Health and Environment (CDPHE)

Specialty Code: 636

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• None

Specialty Code: 682

Additional Requirements:

• Copy of one of the following IRS documents
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Approval from CDPHE

• Assisted Living Residence License or Home Care Agency Class A License from the Colorado Department of Public Health and Environment
• Recommendation of approval from the Colorado Department of Public Health and Environment
  • Commission of the Accreditation of Rehabilitation Facilities (CARF) accreditation may waive the on-site review for initial certification. However, on-site reviews of all programs shall occur on at least a yearly basis.

Specialty Code: 685

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• None

Specialty Code: 687

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers

Required Certifications and/or Licenses:

• Optometry license from the Colorado Department of Regulatory Agencies (DORA).
• License from the Colorado Dept. of Regulatory Agencies or of out-of-state license from own state.

Specialty Code: 751

Additional Requirements:

• Copy of one of the following IRS documents for EIN enrollments only
  • SS-4 Employer Identification Number Assignment
  • IRS 147c EIN Verification letter
• Copy of the Affidavit of Lawful Presence for SSN enrollments only
  • Photocopy of government issued photo ID (i.e. Driver License) must be attached to application
  • Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms"
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.
• Copy of W-9 signed within last six months.
  • Address must match one address listed on the application
  • DBA (Trade Name) must be listed on Line 2 if included on the application.
• Voided check or signed bank letter
  • Voided check or bank letter address must match an address on the application
  • If bank letter is submitted, the letter must be signed by the bank within the last six months.
    • Must include account and routing numbers
• Electronic Visit Verification is required for some services billed under this specialty code and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid Program).For additional information visit the EVV web page.

Required Certifications and/or Licenses:

• A copy of an approved Program Approved Service Agency (PASA) application from the Colorado Department of Public Health and Environment OR
  A signed attestation on the provider's letterhead that states the provider is an established PASA.
• Recommendation of approval from the Colorado Department of Public Health and Environment (CDPHE).