Information by Provider Type

Click on the provider types below for more enrollment details.

Administrative Services Organization (ASO)
Provider Type 81

Specialty: Transportation
Specialty Code: 810
OR
Specialty: Dental
Specialty Code: 811

Enrollment Type: Atypical

  • Contract with the Department
  • Each service location must complete a separate application
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application)
    • Transportation-810 ASO must have enrolled and affiliated providers
    • Dental-811 ASO does not require affiliations, however, providers must also enroll separately with the Dental ASO

Required Attachments:

  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Ambulatory Surgery Center (ASC)
Provider Type: 44

Specialty: Ambulatory Surgery Center
Specialty Code: 300

Enrollment Type: Facility

  • Each location must complete a separate application and pay a separate application fee

Required Attachments:

  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Audiologist
Provider Type: 19

Specialty: Audiologist
Specialty Code: 310

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - directly bills for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations

Required Attachments:

  • License

Additional Attachments for Billing Individuals ONLY:

  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes - with proof of a Colorado License
Behavioral Therapy - Clinic
Provider Type: 83 Please read the definition below before choosing this provider type

Specialty: Behavioral Therapy Clinic
Specialty Code: 830

Enrollment Type: Group

Definition:: services for children/youth under age 21 who have an autism spectrum disorder or similar condition: Health First Colorado Criteria for Behavioral Therapy

IMPORTANT: If you are a Behavioral Health provider serving individuals with mental illness and/or substance use disorders, do NOT select this provider type. Please refer to information for Non-Physician Practitioner Groups (25) and/or Substance Use Disorder Clinics (64).

  • Each service location must complete a separate application

  • Credentialed professionals (the rendering providers) must be enrolled individually (separate application), and affiliated with the clinic. Affiliations are restricted to Provider Type 84, Specialty 831-Behavioral Therapist, Provider Type 37, Specialty 520-Licensed Psychologist, Provider Type 38, Specialty 521 Licensed Behavioral Health Clinician.

  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners

  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.

Required Attachments:

  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Completed Behavioral Therapy Provider Attestation Form for the Behavioral Therapist(PT84) who will affiliate with the clinic. Attach evidence of license, credential, training and/or experience as indicated in the form. (NOTE: Submission of the Attestation form is not required for Provider type 37 - Licensed Psychologist or Provider Type 38 - Licensed Behavioral Health Clinician who may be affiliating to the clinic.)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Behavioral Therapy - Individual
Provider Type: 84

Specialty: Behavioral Therapist
Specialty Code: 831

Enrollment Type: Individual within a Group - affiliates to a group and the group bills OR

Billing Individual - bills directly for themselves

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Individual within a Group enrollments may only affiliate with a Behavioral Therapy Clinic, and/or Non-Physician Practitioner Group.
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.

Required Attachments:

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
  • Behavioral Therapy Provider Attestation Form must be completed
    • Evidence of license, credential, training and/or experience must be included

Additional Attachments for Billing Individual ONLY:

  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Billing Agent
THIS Provider type IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS. A Trading Partner ID (TPID) is required to submit batch claims or batch eligibility files. Visit the Trading Partner page for additional information regarding TPIDs.
Birthing Center
Provider type: 58

Specialty: Free Standing Birthing Center
Specialty Code: 116

Enrollment Type: Group

  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the group. Rendering providers must be Certified Nurse Midwives or Physicians

  • No Direct Entry Midwives (non-DORA certified) are to be enrolled

  • For new enrollments, the group must be approved prior to enrollment of the individual practitioners

  • Each service location must complete a separate application

Required Attachments:

  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Copy of the individual license for the Certified Nurse Midwife (CNM) or Physician who will affiliate to the Birthing Center
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Case Management Agency
Provider type: 11

Specialty: Contracted Case Management
Specialty Code: 330

Enrollment Type: Atypical

  • Contract with the Department
  • Each service location must complete a separate application
  • EFT Exemption Instructions (to bypass the Electronic Funds Transfer (EFT) requirement)

Required Attachments:

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No BT Allowed? No

 

Specialty: Targeted Case Management/Transition Services (TCM/TS)
Specialty Code:770

Enrollment Type: Atypical

  • Each service location must complete a separate application

Required Attachments:

Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Certified Addiction Counselor (CAC)
Special Instructions:
  • Per 10 CCR 2505-10 8.746 Health First Colorado (Colorado's Health First Colorado program)cannot enroll a CAC who isn't also a licensed health professional (advanced practice nurse, physician/psychiatrist, physician assistant.)
Certified Registered Nurse Anesthetist (CRNA)
Provider type: 40

Specialty: Certified Registered Nurse Anesthetist (CRNA)
Specialty Code: 340

Enrollment Type: Individual within a Group - affiliates to a group and the group bills

Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations

Required Attachments:

  • License

Additional Attachments for Billing Individuals ONLY:

  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID&/li>
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Clinic - Dental
Provider Type:47 Specialty: Clinic - Dental
Specialty Code:350

Enrollment Type: Group

  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • For new enrollments, the clinic must be approved prior to enrollment of the individual dentists and dental hygienists
  • Dental clinics must be owned by one of the following entities per 12-220-114, C.R.S. (formerly 12-35-116.5):
    • a licensed dentist or dental hygienist
    • a political subdivision - such as a county
    • a non-profit corporation
    • a non-licensed heir of a deceased licensed dentist
  • Each service location must complete a separate application
Required Attachments:
  • License of the dentist or dental hygienist who owns the clinic
  • Certificate of Good Standing issued by the Colorado Secretary of State for a non-profit corporation ONLY
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Clinic - Practitioner
Provider Type:16 Specialty: Clinic - Practitioner
Specialty Code: 351

Enrollment Type: Group

  • Must have at least one enrolled, licensed practitioner (MD, DO, OD or DPM) affiliated with the clinic
  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • Each service location must complete a separate application
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • Copy of the individual license for the MD, DO, OD or DPM who will affiliate to the clinic
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Community Clinic
Provider Type:86
Specialty: Community Clinic or Community Clinic & Emergency Center
Specialty Code: 860

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Professional services must be submitted by the professional. Community Clinics do not have individual associations.
Required Attachments:
  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • Medicare approval as a Community Clinic or Community Clinic & Emergency Center at the same service location address
  • Proof of JCAHO accreditation (optional)
  • License as a Community Clinic or Community Clinic & Emergency Center
  • Affiliation Addendum to the Hospital license showing the service location address is affiliated to a certain hospital
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Community Mental Health Center
Provider Type:35
Specialty: Community Mental Health Center
Specialty Code: 360

Enrollment Type: Group

  • Must have at least one enrolled, licensed practitioner affiliated with the clinic
  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • Each service location must complete a separate application
Required Attachments:
  • License
  • Copy of the individual license for the Physician (provider type 05), Osteopath (provider type 26), Licensed Behavioral Health Clinician (provider type 38), or Licensed Psychologist (provider type 37) who will affiliate to the clinic.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Dental Hygienist
Provider Type:66
Specialty: Dental Hygienist
Specialty Code: 066

Enrollment Type: Individual within a Group – affiliates to a group and the group bills
OR
Billing Individual – bills directly for themselves

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
Required Attachments:
  • License
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Dentist
Provider Type:04
Specialty: Oral Surgery
Specialty Code: 061
OR Specialty: Dentist
Specialty Code: 062
OR Specialty: Orthodontist
Specialty Code: 063

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
OR
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License –Two separate licenses required - Dental and Physician for Oral Surgery specialty ONLY
    • in lieu of the physician license, a copy of the Oral Maxillofacial Surgery (OMFS) certification and hospital privileges are required
  • License –Dental required for Dentist and Orthodontist specialties
  • National Specialty Board Certification for Orthodontist specialty ONLY
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Dermatologist or Dermatology Clinic
Special Instructions:
  • Dermatologists should enroll as the 'physician' provider type, and indicate dermatology as a specialty through the taxonomy code.
  • A dermatology clinic should enroll as the 'Clinic - Practitioner' provider type and indicate dermatology as a specialty through the taxonomy code.
    • On the first page of the application, make sure to indicate a dermatology specialty using the taxonomy code.
    • On the second page of the application, choose 'Clinic/Center' from the dropdown list; there isn't a dermatology option listed here.
Developmental Evaluation Clinic
Provider Type:46 Specialty: Developmental Evaluation Clinic
Specialty Code: 370

Enrollment Type: Group

  • Each location must complete a separate application.
  • Medical Director must be enrolled (separate application), and associated with the clinic.
  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
Required Attachments:
  • License from the Colorado Department of Public Health and Environment
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Dialysis Center
Provider Type:33
Specialty: Dialysis Center
Specialty Code: 375

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
Required Attachments:
  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? No BT Allowed? Yes
Durable Medical Equipment (DME)
Special Instructions:
  • Please see 'Supply Facility', 'Supply Billing Individual', or 'Pharmacy (Pharmacy with DME)'
Family Planning Clinic
THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS. Family planning services currently may be provided under the Clinic – Practitioner or Non-Physician Practitioner – Group, provider types. Please review those provider type requirements to select the appropriate entity based on your credentialed professionals.

 

Federally Qualified Health Center
Provider Type:32 Specialty: Freestanding
Specialty Code: 150
OR Specialty: Hospital Based
Specialty Code: 160
OR Specialty: Denver Health and Hospital School Based Clinics
Specialty Code: 199

Enrollment Type: Group

  • Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. you do NOT need to complete a separate application for mental health or dental services since they are occurring at the same site location). However, you will need to complete a separate application for a pharmacy ID (if applicable).
  • Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.
Required Attachments:
  • HRSA Notice of Award of a Section 330 Grant, or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare, OR receives HRSA designation as a look-alike entity, OR self-identifies as receiving funds under Title V of the Indian Health Care Improvement Act.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes (Only for Specialties 150 and 160) BT Allowed? Yes (Only for Specialties 150 and 160)
Foreign Teaching Physician
Provider Type:65 Specialty: Foreign Teaching Physician
Specialty Code: 500

Enrollment Type: Individual within a Group – affiliates to a group and the group bills

  • Complete only one enrollment application regardless of number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Health Maintenance Organization (HMO)
Provider Type: 23 Specialty: Health Maintenance Organization (HMO)
Specialty Code: 391
OR Specialty: Health Maintenance Organization (HMO)/PACE
Specialty Code: 393

Enrollment Type: Atypical

  • Contract with the Department
  • Each service location must complete a separate application
  • Credentialed professionals (rendering, ordering, prescribing and referring providers) in HMO networks must be enrolled individually (separate application)
Required Attachments:
  • License from the Colorado Division of Insurance - HMO Specialty 391 ONLY
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level Limited Fee Req'd? No NPI Req'd? Yes-HMO/PACE-393, No-HMO-391
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Home & Community Based Services (HCBS)
Provider Type: 36 Special Instructions:
Home Health
Provider Type:10 Specialty: Home Health
Specialty Code: 385

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • 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.
Required Attachments:
  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: High Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospice
Provider Type:50 Specialty: Hospice
Specialty Code: 390

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • 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.
Required Attachments:
  • License (License must include the service location address)
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospital - General
Provider Type:01 Specialty: Hospital - General
Specialty Code: 301

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
Required Attachments:
  • License (License must include an address that matches the service location address on the provider application)
    • If this is an Off Campus Location (OCL), attach the hospital license and OCL addendum showing the matching service location address (including suite number if applicable). CLIA may be waived if this OCL does not do laboratory testing.
  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospital - Mental
Provider Type:02 Specialty: Hospital - Mental
Specialty Code: 302

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Professional services must be submitted by the professional. Hospitals do not have individual associations.
  • A contract with the Department of Health Care Policy and Financing is required (in-state only).
Required Attachments:
  • License (License must include an address that matches the service location address on the provider application)
  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • Proof of JCAHO accreditation (optional)
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? No BT Allowed? No
Independent Laboratory
Provider Type:12 Specialty: Independent Laboratory
Specialty Code: 410

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
Required Attachments:
  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Indian Health Services - FQHC
Provider Type:61 Specialty: Indian Health Services
Specialty Code: 170

Enrollment Type: Group

  • Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. a separate application is NOT required for mental health or dental services since they are occurring at the same site location). A separate application is required for a pharmacy (if applicable).
  • Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.
Required Attachments:
  • HRSA Notice of Award of a Section 330 Grant, or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare, OR receives HRSA designation as a look-alike entity, OR self-identifies as an IHS facility under the U.S. Department of Health and Human Services OR receives funds under Title V of the Indian Health Care Improvement Act.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Indian Health Services - Pharmacy
Provider Type:62 Specialty: Indian Health Services
Specialty Code: 420

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • Each pharmacy service location must have a unique National Provider Identifier (NPI)
  • Dispensing Fee Attestation Worksheet must be completed (part of the online application)
  • Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questionnaire will still appear in the application, however due to legislative changes it is no longer required to be completed.
Required Attachments:
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Licensed Addiction Counselor (LAC)
Special Instructions:
  • There is not a provider type called "Licensed Addiction Counselor". LACs should use the provider type "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LAC.) LAC is indicated through the taxonomy code.
Licensed Behavioral Health Clinician
Provider Type:38 Specialty: Licensed Behavioral Health Clinician
Specialty Code: 521

Enrollment Type: Individual within a Group – affiliates to a group and the group bills
OR
Billing Individual – bills directly for themselves

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License (LAC, LCSW, LPC, or LMFT)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
ADDITIONAL ATTACHMENTS for BILLING INDIVIDUAL ONLY:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Licensed Clinical Social Worker (LCSW)
Special Instructions:
  • There is not a provider type called "Licensed Clinical Social Worker". LCSWs should use the provider type "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LCSW.) LCSW is indicated through the taxonomy code.
Licensed Marriage and Family Therapist (LMFT)
Special Instructions:
  • There is not a provider type called "Licensed Marriage and Family Therapist". LMFTs should use the provider type "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LMFT.) LMFT is indicated through the taxonomy code.
Licensed Professional Counselor (LPC)
Special Instructions:
  • There is not a provider type called "Licensed Professional Counselor". LPCs should use the provider type "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LPC.) LPC is indicated through the taxonomy code.
Licensed Psychologist
Provider Type:37 Specialty: Licensed Psychologist (PhD, PsyD, EdD)
Specialty Code: 520

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Local Public Health Agencies (LPHA)
Special Instructions:
  • There is not a provider type called "Local Public Health Agency". LPHAs should use the provider type "Clinic-Practitioner" or "Non-Physician Practitioner-Group" and the ‘Group’ enrollment type. Please review the specific requirements for these Provider Types to verify which is applicable.
  • For the application process to be completed, a minimum of three applications are required:
    1. one for the organization (either a Clinic-Practitioner or a Non-Physician Practitioner-Group)
    2. one for an individual enrollment for the supervising MD/DO (Clinic-Practitioner) or NP (Non-Physician Practitioner-Group)
    3. one for an individual enrollment for the RN
      NOTE: An RN is required to be supervised by a qualified MD/DO/NP and the RN must complete the RN supervision area in the application.
    • The organization must be enrolled first, before the individual(s) that work at the clinic.
    • Additional applications must be submitted for each of the individuals that are affiliating with the clinic.
  • If you are a county agency that reimburses for or provides non-emergency medical transportation (NEMT), you must also enroll as:
    • Enrollment Type: Atypical
    • Provider Type: 73 – Transportation
    • Specialty Code: Non-emergency medical (525)
  • If you are a county that is also an emergency ambulance provider, you must also enroll as:
    • Enrollment Type: Facility
    • Provider Type: 13- Transportation
    • Specialty Code: County Agency, Non Metro Area (124)
Managed Care Organization (MCO)
Special Instructions:
  • Please see the provider type 'Health Maintenance Organization (HMO)'
Non-Physician Practitioner - Group
Provider Type:25 Specialty: Non-Physician Practitioner - Group
Specialty Code: 441

Enrollment Type: Group

  • Must have at least one licensed Behavioral Health Clinician, Psychologist, Nurse Practitioner, Nurse Midwife, Certified Registered Nurse Anesthetist, Physical Therapist, Occupational Therapist, Speech Therapist, Audiologist, or Behavioral Therapist affiliated with the clinic. NOTE: Behavioral Therapists must submit either BCBA certification or Behavioral Therapy Attestation Form.
  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners.
  • Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
  • Each service location must complete a separate application
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • Copy of the individual license/certification/attestation form for the individual provider mentioned above who will affiliate to the Group
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Non-Physician Practitioner - Individual
Provider Type:24 Specialty: Non-Physician Practitioner - Individual
Specialty Code: 440

Enrollment Type: Individual within a Group – affiliates to a group and the group bills

  • This provider type is for Registered Nurses (RNs) only.
  • NOTE: Certified Registered Nurse Anesthetists, Nurse Practitioners and Nurse Midwives have their own provider types
  • Complete only one enrollment application regardless of number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License
  • RN Supervision form
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Nurse Practitioner
Provider Type:41 Specialty: Pediatric
Specialty Code: 034
AND/OR Specialty: Family
Specialty Code: 035
AND/OR Specialty: General
Specialty Code: 335

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License (APN, CNS, NP, FNP, PNP)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Nurse-Midwife
Provider Type:22 Specialty: Nurse-Midwife
Specialty Code: 080

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Nursing Facility
Provider Type:20 Specialty: Nursing Facility - Hospital Back Up Program
Specialty Code: 382
OR Specialty: Nursing Facility - Regular
Specialty Code: 392
OR Specialty: Nursing Facility - Swing Beds
Specialty Code: 396

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Nursing Facility service location addresses must be in Colorado, only in special cases are out of state service locations accepted.
Required Attachments:
  • License
  • Proof of Malpractice/Liability Insurance
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
(396), No (382, 392)
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Restricted BT Allowed? Yes
Nursing Facility - ICF/IID
Provider Type:21 Specialty: ICF/IID - Private
Specialty Code: 383
OR Specialty: ICF/IID - State
Specialty Code: 394

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • Service location addresses must be in Colorado, only in special cases are out of state service locations accepted.
Required Attachments:
  • License
  • Proof of Malpractice/Liability Insurance
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Restricted BT Allowed? Yes
Occupational Therapist
Provider Type:28
Specialty: Occupational Therapist
Specialty Code: 450

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Optical Outlet
Provider Type:08
Specialty: Optical Outlet
Specialty Code: 395

Enrollment Type: Facility

  • Each service location must complete a separate application
Required Attachments:
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes   BT Allowed? Yes
Optometrist
Provider Type:07
Specialty: Optometrist
Specialty Code: 183

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Osteopath
Provider Type:26
Specialty: Osteopath
Specialty Code: 501

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Personal Care Agency
Provider Type:60
Specialty: Personal Care Agency
Specialty Code: 560

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • This provider type is only for pediatric personal care benefit members. Please visit the Personal Care benefit page for more information.
  • The closest NPI taxonomy code is Nursing & Custodial Care Facilities - Custodial Care Facility - 311Z00000X
  • 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.
Required Attachments:
  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: High Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Pharmacist
Provider Type:75
Specialty: Pharmacist
Specialty Code: 750

Enrollment Type: Individual within a Group – affiliates to a group and the group bills

  • Must affiliate to at least one Pharmacy (PT 09) and/or Indian Health Services (IHS) Pharmacy (PT 62); may affiliate to multiple Pharmacies or IHS Pharmacies on one enrollment application (if applicable).
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Pharmacy
Provider Type:09
ATTENTION ALL PHARMACIES! In order to bill any type of Durable Medical Equipment and Supplies (DME) to Medicaid, you must also select the specialty type "Pharmacy with DME" on your provider application. That specialty type is required even if your pharmacy qualifies for the Medicare exemption from DME accreditation. If you select any other pharmacy specialty, your pharmacy will not be able to bill any DME to Medicaid. Please be advised that "Pharmacy with DME" is a high-risk level specialty that is subject to additional screening requirements. Specialty: Mail Order
Specialty Code: 460
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Pharmacy
Specialty Code: 461
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Pharmacy with DME
Specialty Code: 462
Risk Level: High Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
OR Specialty: Rural Dispensing Physician Site
Specialty Code: 463
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes

Enrollment Type: Facility

  • Each pharmacy service location must complete a separate application
  • Pharmacy with DME (specialty code 462) must pay an application fee with each application
  • Each pharmacy service location must have a unique National Provider Identifier (NPI)
  • Pharmacy Dispensing Fee Addendum must be completed (part of the online application)
  • Pharmacy with DME (462) ONLY - Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • Colorado Pharmacy License (Specialty 463 ONLY-license may be from other state if in a border town)
  • Copy of the individual physician’s license for the Rural Dispensing Physician Site ONLY
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Physical Therapist
Provider Type:17 Specialty: Physical Therapist
Specialty Code: 451

Enrollment Type: Individual within a Group - affiliates to a group and the group bills OR
Billing Individual - directly bills for themselves

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Moderate Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Physician
Provider Type:05
Specialty: Physician
Specialty Code: 505

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations

Osteopaths (DO): do not select this provider type. Osteopaths must select Provider Type 26/501.

Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Physician Assistant
Provider Type:39
Specialty: Physician Assistant
Specialty Code: 510

Enrollment Type: Individual within a Group – affiliates to a group and the group bills
Ordering, Referring, Prescribing – limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Podiatrist
Provider Type:06 Specialty: Podiatrist
Specialty Code: 194

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Psychiatric Residential Treatment Facility
Provider Type:30
Specialty: Psychiatric Residential Treatment Facility
Specialty Code: 476

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
Required Attachments:
  • Department of Human Services - Division of Child Welfare License as a Psychiatric Residential Treatment Facility (Required for in-state providers only)
  • Department of Human Services - Division of Child Welfare License as a Residential Child Care Facility (Required for in-state providers only)
  • Department of Human Services, Office of Behavioral Health Attestation Letter (Required for in-state providers only)
  • Psychiatric Residential Treatment Facility located in another state must submit all license and certification requirements for a PRTF in the state in which it is located.
  • Accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.
  • Provide an attestation indicating the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in 10 CCR 2505-10 Section 8.765.6.F and in federal law.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Psychologist - Bachelors
Special Instructions:
  • Per 10 CCR 2505-10, Colorado Medicaid cannot enroll a Psychologist who doesn't meet Masters or Doctorate level education requirements
QMB Benefits Only
Provider Type:18
Specialty: QMB Benefits Only
Specialty Code: 321

Enrollment Type: Billing Individual – directly bills for themselves

  • This provider type is for Chiropractors only
  • Complete only one enrollment application regardless of enrollment type and number of service locations
Required Attachments:
  • License
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Lawful Presence form and copy of Identification
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Regional Accountable Entity (RAE)
Provider Type:85
Specialty: Regional Accountable Entity
Specialty Code: 850

Enrollment Type: Atypical

  • Contract with the Department
  • Each region must complete a separate application
  • PCMP (Primary Care Medical Provider) staff (MD/DO, NP, PA, etc.) must enroll separately
Required Attachments:
  • Colorado Division of Insurance specifically for either:
    • Health Maintenance Organization (HMO), OR
    • Limited Service Licensed Provider Network (LSLPN)
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Registered Nurse
Special Instructions:
  • See Non-Physician Practitioner - Individual
Rehabilitation Agency
Provider Type:48 Specialty: Practitioner
Specialty Code: 397
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Comprehensive Outpatient Rehabilitation Facility
Specialty Code: 470
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes

Enrollment Type: Group

  • Practitioner specialty must have at least one enrolled, licensed physical, occupational, or speech therapist affiliated with the group
  • Comprehensive Outpatient Rehabilitation Facility specialty must have at least one enrolled, licensed practitioner (MD, DO, OD or DPM) affiliated with the group
  • For new enrollments, the group must be approved prior to enrollment of the individual practitioners
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • Each service location must complete a separate application
  • Comprehensive Outpatient Rehabilitation Facility must pay an application fee with each application
  • Practitioner (397) only - Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • Copy of the individual license for the individual provider mentioned above who will affiliate to the group.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Residential Child Care Facility
Provider Type:52 Specialty: Mental Health Program
Specialty Code: 471

Enrollment Type: Group

  • Must have at least one enrolled, licensed psychologist or physician affiliated with the group
  • For new enrollments, the group must be approved prior to enrollment of the individual practitioners
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • Each service location must complete a separate application
Required Attachments:
  • Department of Human Services Permanent Child Care License indicating Service Type as: Residential Child Care Facility.
  • Department of Human Services Office of Behavioral Health Attestation letter of a successful site review for providing mental health services (required for in-state providers only)
  • Copy of the individual license for the physician or psychologist who will affiliate to the group
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Rural Health Clinic
Provider Type:45 Specialty: Hospital Based
Specialty Code: 398
OR Specialty: Freestanding
Specialty Code: 472

Enrollment Type: Group

  • Must have at least one enrolled, licensed physician, osteopath, advanced practice nurse or physician assistant affiliated with the clinic
  • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
  • Each service location must complete a separate application
Required Attachments:
  • Medicare Rate Sheet
  • Provider's Cost Report
  • Copy of the individual license for the physician, osteopath, advanced practice nurse or physician assistant who will affiliate to the clinic
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
School Health Services
Provider Type:51
Specialty: School Health Services
Specialty Code: 475

Enrollment Type: Facility

  • Individual School Health Services providers do not have to be enrolled.
  • Each school district must complete a separate application.
  • For the "Disclosures" section of the application, school districts only need to disclose their superintendent and CFO rather than their elected board of officials. The superintendent and CFO information must be entered in the Managing employee section (Section D) of the disclosures page. Please indicate "CFO" or "Superintendent" following the listed individual's name.
Required Attachments:
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Speech Therapist
Provider Type:27
Specialty: Speech Therapist
Specialty Code: 452

Enrollment Type: Individual within a Group - affiliates to a group and the group bills
Billing Individual - bills directly for themselves
OR
Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
Required Attachments:
  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Additional Attachments For Billing Individuals Only:
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Affidavit of Lawful Presence form and government-issued photo ID
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Substance Use Disorder - Clinics
Provider Type:64
Specialty: Substance Use Disorder - Clinics
Specialty Code: 477

Enrollment Type: Facility

  • Each location must complete a separate application.
Required Attachments:
  • Department of Human Services Office of Behavioral Health License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Specialty: Special Connections
Specialty Code: 870

Enrollment Type: Facility

  • Each location must complete a separate application.
  • Must have an enrolled, approved, active provider type 64-SUD Clinic with specialty 477-SUD Clinic, ASAM 3.1, ASAM 3.5, ASAM 3.7 or ASAM 3.7 WM prior to approval of this specialty -OR- be enrolling for one of the specialties indicated previously and this specialty at the same time.
Required Attachments:
  • Department of Human Services, Office of Behavioral Health License (specific to "Gender Responsive Treatment")
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Specialty: ASAM Level 3.1 CMLIRS (Clinically Managed Low-Intensity Residential Services)
Specialty Code: 871 Specialty: ASAM Level 3.3 CMPSHIRS (Clinically Managed Population-Specific High-Intensity Residential Services)
Specialty Code: 872 Specialty: ASAM Level 3.5 CMHIRS (Clinically Managed High-Intensity Residential Services)
Specialty Code: 873 Specialty: ASAM Level 3.7 MMIIS (Medically Monitored Intensive Inpatient Services)
Specialty Code: 874 Specialty: ASAM Level 3.2 WM CMRWM (Clinically Managed Residential Withdrawal Management)
Specialty Code: 875 Specialty: ASAM Level 3.7 WM MMIWM (Medically Monitored Inpatient Withdrawal Management)
Specialty Code: 876

Enrollment Type: Facility

  • Each location must complete a separate application.
Required Attachments:
  • Department of Human Services, Office of Behavioral Health License (specific to the ASAM level being enrolled)
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Substance Use Disorder - Individuals
THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS. Services may be provided under the "Licensed Behavioral Health Clinician" Provider Type.

 

Supply
Provider Type:74
Specialty: Durable Medical Equipment (DME) (SSN Only)
Specialty Code: 480

ENROLLMENT TYPE: Billing Individual – directly bills for themselves

  • Complete only one enrollment application
  • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the DMEPOS benefit manager at Alex.Weichselbaum@state.co.us prior to submitting an enrollment application. Please include a contact name and phone number.

Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screen print from the accreditation agency's website
  • Sales Tax Certificate or Tax Exempt Certificate – (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
  • W9 (signed and dated within last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Lawful Presence form and copy of Identification
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: High Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional

 

Provider Type:14
Specialty: Complex Rehabilitation Technology (CRT) (EIN Only)
Specialty Code: 481

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
  • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the DMEPOS benefit manager at Alex.Weichselbaum@state.co.us prior to submitting an enrollment application. Please include a contact name and phone number.
Required Attachments:
  • CRT Supplier Accreditation
  • CRT Professional Certification
  • Member letter for accessing service and repair
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screen print from the accreditation agency's website
  • Sales Tax Certificate or Tax Exempt Certificate – (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: High Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional

 

Specialty: Durable Medical Equipment (DME) (EIN Only)
Specialty Code: 482

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification (EVV) Attestation Form. For additional information visit the EVV web page.
  • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the DMEPOS benefit manager at Alex.Weichselbaum@state.co.us prior to submitting an enrollment application. Please include a contact name and phone number.
Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screen print from the accreditation agency's website
  • Sales Tax Certificate or Tax Exempt Certificate – (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: High Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional
Transportation
Provider Type:13 - Emergency Medical Transportation and Air Ambulance
Specialty: Air - Emergent & Non-Emergent
Specialty Code: 086

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
Required Attachments:
  • License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Specialty: County Agency, Non Metro Area
Specialty Code: 124

Enrollment Type: Facility

  • Each service location must complete a separate application
Required Attachments:
  • Ambulance License
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Specialty: Emergency
Specialty Code: 324

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee
Required Attachments:
  • Ambulance license
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes

 

Provider Type:73 - Non-Emergent Medical Transportation
Specialty: Non-Emergency Medical - Broker Network Participant
Specialty Code: 326

Enrollment Type: Atypical

 

  • Each service location must complete a separate application
  • This is for non-emergency medical transportation (NEMT) providers, that are a part of IntelliRide's network. If you are a NEMT provider in any of the following counties, you must be enrolled with IntelliRide: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, Weld.
Required Attachments:
  • PUC license or local county ambulance license, if applicable. To obtain a PUC Medicaid Transportation Permit (MCT) follow the directions outlined on the NEMT Provisional Agreement.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
No
Risk Level: Moderate Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No   BT Allowed?

 

Specialty: Non-Emergency Medical - Outside Broker Service Area
Specialty Code: 525

Enrollment Type: Atypical

  • Each service location must complete a separate application
  • This is for non-emergency medical transportation (NEMT) providers, including county departments of human services, that provide services in any county outside of: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, Weld.
Required Attachments:
  • PUC license or local county ambulance license, if applicable. To obtain a PUC Medicaid Transportation Permit (MCT) follow the directions outlined on the NEMT Provisional Agreement.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Lawful Presence form and copy of Identification for Individual/SSN enrollment ONLY
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
X-Ray Facility
Provider Type:49
Specialty: X-Ray Facility
Specialty Code: 495

Enrollment Type: Facility

  • Each business location must complete a separate application and pay a separate application fee.
  • If your business performs MRI procedures only, enroll as provider type 16 – Clinic – Practitioner.
Required Attachments:
  • Department of Public Health and Environment RCD59-1 CE Report required for instate, service address must match the service location address in application. OOS must submit similar document or X-ray license from own state.
  • W9 (signed and dated within last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes