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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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Adult Mental Health Residential

Provider Type: 96

Specialty: Supported Therapeutic Transitional Living
Specialty Code: 561

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • A Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) license with an Adult Mental Health Transitional Living, Level 2 sub-endorsement.
  • W9 (signed and dated within the last 6 months).
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes - with proof of a Colorado License
Behavioral Health ASO

Provider Type: 91

Specialty: BHA Administrative Service Organization (ASO)
Specialty Code: 900

Enrollment Type: Atypical

  • Contract with the Department of Human Services, Behavioral Health Administration.
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Rendering providers must be enrolled separately.

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Behavioral Health Crisis Line

Provider Type: 88

Specialty: Behavioral Health Crisis Line
Specialty Code: 888

Enrollment Type: Atypical

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Proof of Colorado Crisis Services Crisis Line contract with the Colorado Department of Human Services (CDHS), Behavioral Health Administration (BHA)
    • Attach a copy of the contract page(s) that identify the applicant as a Colorado Crisis Services/Crisis Line contractor with CDHS BHA and the signature pages(s).
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Behavioral Health Crisis Services

Provider Type: 95

Specialty: Acute Treatment Unit (ATU)
Specialty Code: 386

Enrollment Type: Group

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05), Physician Assistant (PT 39) or Osteopath (PT 26) affiliated with the group.
  • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
  • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

Required Attachments:

  • Colorado Department of Public Health and Environment (CDPHE) Behavioral Health Entity (BHE) license with a Part 4(B) Acute Treatment Services endorsement or a Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) ATU license.
  • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician, physician assistant or osteopath who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

Specialty: Crisis Stabilization Unit (CSU)
Specialty Code: 387

Enrollment Type: Group

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05), Physician Assistant (PT 39) or Osteopath (PT 26) affiliated with the group.
  • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
  • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

Required Attachments:

  • Colorado Department of Public Health and Environment (CDPHE) Behavioral Health Entity (BHE) license with a Part 4(A) Crisis Stabilization Services endorsement or a Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) CSU license.
  • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician, physician assistant or osteopath who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

Specialty: Mobile Crisis Response
Specialty Code: 772

Enrollment Type: Group

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05) or Osteopath (PT 26) affiliated with the group.
  • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
  • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

Required Attachments:

  • Colorado Department of Human Services Behavioral Health Administration (BHA) license for mobile crisis response services.
  • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician or osteopath who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Behavioral Health Group

Provider Type:77 

Specialty: With Prescriber 
Specialty Code: 388
OR
Specialty: Without Prescriber 
Specialty Code: 389
Enrollment Type: Group

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • With Prescriber:
    • There must be at least one Physician (Provider Type [PT] 05), Osteopath (PT 26), Physician Assistant (PT 39) or Nurse Practitioner (PT 41) AND at least one Licensed Psychologist (PT 37) or Licensed Behavioral Health Clinician (PT 38) who will affiliate with the group. (There must be two copies of licenses attached with the application, one for the Physician, Osteopath, Physician Assistant or Nurse Practitioner AND one for the Licensed Psychologist or Licensed Behavioral Health Clinician who will affiliate with the group.)
  • Without Prescriber
    • Only Licensed Psychologists (PT 37) and Licensed Behavioral Health Clinicians (PT 38) are allowed to affiliate with this specialty. (There must be one copy of the license attached with the application for the Licensed Psychologist or Licensed Behavioral Health Clinician.)
  • 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 group.

Required Attachments:

  • Copy(ies) of the individual license(s) as indicated above for the rendering individual(s) who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?With Prescriber = Yes
Without Prescriber = No		BT Allowed?Yes
Behavioral Health MSO

Provider Type: 92

Specialty: BHA Managed Service Organization (MSO)
Specialty Code: 899

Enrollment Type: Atypical

  • Contract with the Department of Human Services, Behavioral Health Administration
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Rendering providers must be enrolled separately.

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Behavioral Health Secure Transportation

Provider Type: 97
Specialty: Secure Transportation
Specialty Code: 773

Enrollment Type: Atypical

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Board of County Commissioners license for secure transportation services for each county of operation.
  • Board of County Commissioners vehicle permit for each vehicle.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

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

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

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

  • Individual practitioners must have specialized qualifications as shown here: Behavioral Therapy Provider Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
  • Additional resources are available on the Pediatric Behavioral Therapies web page.
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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, or 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 Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Completed Behavioral Therapy Provider Attestation Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, for the Behavioral Therapist (PT 84) 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:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes
Behavioral Therapy - Individual

Provider Type: 84 
Please read the definition below before choosing this provider type.

Specialty: Behavioral Therapist
Specialty Code: 831

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. Refer to information for Licensed Behavioral Health Clinicians (38) or Licensed Psychologists (37).

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.
  • Must enroll using the individual's Social Security Number (SSN).
  • Individual within a Group enrollment may only affiliate with a Behavioral Therapy Clinic.
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

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, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, must be completed.
    • Evidence of license, credential, training and/or experience must be included, e.g. BCBA accreditation.

Additional Attachments for Billing Individual only:

  • W9 (signed and dated within the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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 Information web 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Facility License issued by the Colorado Department of Public Health & Environment (CDPHE)
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (signed and dated within the 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:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • EFT Exemption Instructions located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, (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:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

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

Enrollment Type: Atypical

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

Specialty: Targeted Case Management/HCBS (TCM/HCBS)
Specialty Code: 771

Enrollment Type: Atypical

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • The Notice of Intent to Award for Solicitation letter.
  • W9 (signed and dated within the last 6 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 business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
    • 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.
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Certified Addiction Counselor (CAC)

Special Instructions:

  • Per 10 CCR 2505-10 8.746, Health First Colorado (Colorado's Medicaid program) cannot enroll a CAC who is not also a licensed health professional (advanced practice nurse, physician/psychiatrist, physician assistant, licensed addiction counselor).
Certified Midwife

Provider Type: 80
Specialty: Certified Midwife
Specialty Code: 211

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.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months).
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
  • Affidavit of Lawful Presence Form, which can be found on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Chiropractor - QMB

Provider Type: 18
Specialty: Chiropractor-QMB
Specialty Code: 321

Enrollment Type: Billing Individual – directly bills for themselves

  • This provider type is for Chiropractors for the Qualified Medicare Beneficiary (QMB) program only.
  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, 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:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Clinic - Practitioner

Provider Type: 16
Specialty: Clinic - Practitioner
Specialty Code: 351
OR
Specialty: Telemedicine
Specialty Code: 878

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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Each service location must complete a separate application.
    • The Clinic-Practitioner specialty must enter a physical address for the service location address in the application.
    • The Telemedicine specialty may list a PO Box for the service location address in the application. (Please enter the PO Box in one of the following accepted formats: Box XXXX, PO XXXX, Post Office XXXX or POB XXXX.)
  • Electronic Visit Verification (EVV) is optional with Specialty 351 (not required with Specialty 878). To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
  • Only one of these specialties may be active at a time.
  • The Telemedicine specialty is excluded from participation as a Primary Care Medical Provider (PCMP).

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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Community Clinic

Provider Type: 86
Specialty: Community Clinic or Freestanding Emergency Dep.
Specialty Code: 860

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 The Joint Commission (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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes
Community Mental Health Center

THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS AS OF July 1, 2024. The Community Mental Health Center provider type is being replaced by the Comprehensive Safety Net Provider. Please review the requirements indicated for the Comprehensive Safety Net Provider.

Community Support Services Provider

Provider Type: 89

Specialty: Recovery Support Services Organization
Specialty Code: 889

Enrollment Type: Group

  • Must have at least one enrolled, licensed practitioner (PT 05-Physician, PT 26-Osteopath, PT 41-Nurse Practitioner, PT 39-Physician Assistant, PT 37 Licensed Psychologist (PhD, PsyD, EdD) or PT 38- Licensed Behavioral Health Clinician [ACD/LAC, CSW, LPC, MFT]) affiliated with the organization.
  • For new enrollments, the organization must be approved prior to enrollment of the individual practitioners.
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the organization.
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • A contract with a Regional Accountable Entity (RAE) is required after the enrollment is approved.

Required Attachments:

  • Department of Human Services, Behavioral Health Administration (BHA) License as a Recovery Support Services Organization.
  • Copy of the individual license for the Physician, Osteopath, Nurse Practitioner, Physician Assistant, Licensed Psychologist (PhD, PsyD, EdD) or Licensed Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) who will affiliate to the organization.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

Specialty: Supportive Housing Provider
Specialty Code: 208

Enrollment Type: Group

  • Must have at least one enrolled behavioral health provider PT 37 Licensed Psychologist (PhD, PsyD, EdD) or PT 38- Licensed Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) affiliated with the group.
  • For new enrollments, the organization must be approved prior to enrollment of the individual practitioners.
  • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the organization.
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Colorado Department of Local Affairs (DOLA) Division of Housing (DOH) Memorandum with certification number and approval as a Supportive Housing Provider. (Complete the Certification data in the application.)
  • Copy of the individual license for the Licensed Psychologist or Licensed Behavioral Health Clinician who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Comprehensive Safety Net Provider

Provider Type: 78

Specialty: Comprehensive Community Behavioral Health Provider
Specialty Code: 887

Enrollment Type: Group

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Must have at least one enrolled, licensed Physician (Provider Type 05), Osteopath (Provider Type 26), Licensed Behavioral Health Clinician (Provider Type 38), or Licensed Psychologist (Provider Type 37) affiliated with the group.
  • Credentialed individuals (rendering providers) must be enrolled individually (separate application) and affiliated with the group.
  • For new enrollments, the group must be approved prior to enrollment of the individual practitioners.

Required Attachments:

  • Behavioral Health Administration license as a Behavioral Health Entity. (Attach a copy of the current license and complete the license information in the application.)
  • Behavioral Health Administration approval letter as a Comprehensive Provider. (Attach a copy of the current approval letter and enter the information in the license section of the application.)
  • Copy of the individual’s license (indicated above), who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes
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.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Dental Therapist

Provider Type: 98
Specialty: Dental Therapist
Specialty Code: 776

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

  • Individuals complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License (Attach a copy of current license and complete the license information.)
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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 drop-down list; there is not 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?NoBT Allowed?Yes
Direct Entry or Certified Professional Midwife

Provider Type: 69

Specialty: DEM/CPM
Specialty Code: 361

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

  • Individuals complete only one enrollment application and must affiliate to at least one enrolled Birthing Center. Multiple affiliations can be indicated in the application when applicable. (Affiliations to other groups/clinics are not acceptable.)
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Doula

Provider Type: 79
Specialty: Doula
Specialty Code: 210

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

  • Individuals complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • Completed Doula Provider Attestation Form and supporting documents.
  • 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 the last 6 months).
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
  • Affidavit of Lawful Presence form, located on the Provider Forms web page under the Provider Enrollment and Update Forms dropdown, and a government-issued photo ID.
Risk Level:HighFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Durable Medical Equipment (DME)

Special Instructions:

  • Refer to '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. 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • The Health Resources and Services Administration (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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS 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.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Health Maintenance Organization (HMO)/Preferred Provider Organization (PPO)

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
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk LevelLimitedFee Req'd?NoNPI Req'd?Yes-HMO/PACE-393, No-HMO-391
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No

 

Specialty: D-SNP HMO/PPO (Dual Special Needs Programs)
Specialty Code: 400

  • Contract with the Department
  • Each service location must complete a separate application
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Credentialed professionals (rendering, ordering, prescribing and referring providers) in HMO networks must be enrolled individually (separate application)
  • Border towns and out-of-state locations are allowed on a case-by-case basis with State approval.
  • This specialty is stand alone (cannot be combined with other specialties) and an NPI is not allowed due to reporting requirements.

Required Attachments:

  • License from the Colorado Division of Insurance
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk LevelLimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
Home & Community Based Services (HCBS)

Provider Type: 36 Special Instructions:

Home Health (also includes Private Duty Nursing)

Provider Type: 10
Specialty: Home Health
Specialty Code: 385

Enrollment Type: Facility

This specialty includes Home Health and Private Duty Nursing.

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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). Visit the EVV web page for additional information.

Required Attachments:

  • In-state providers must possess a Class A Home Health Agency license issued from the Colorado Department of Public Health and Environment.
  • Out-of-state providers must possess a Home Health Agency license issued by their own state.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:HighFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Effective 7/1/2024, Electronic Visit Verification (EVV) is no longer required for Hospice providers.

Required Attachments:

  • License (License must include the service location address)
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Distinct Part Units (DPUs) are not recognized separately from the General Hospital under which they are licensed and are not enrolled separately.

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). Clinical Laboratory Improvement Amendments (CLIA) may be waived if this OCL does not do laboratory testing.
  • CLIA certificate: A copy of the current CLIA certificate must be attached.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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: A copy of the current CLIA certificate must be attached.
  • Proof of The Joint Commission (JCAHO) accreditation (optional)
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?NoBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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).
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.

Required Attachments:

  • The Health Resources and Services Administration (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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Insurance information must be entered in the application. Federal Tort Claims Act (FTCA) is acceptable in lieu of malpractice/liability. Proof of coverage is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

Required Attachments:

  • License (ACD/LAC, CSW, LPC, or MFT)
  • 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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed? YesBT 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. Review the specific requirements for these provider types to verify which is applicable.
  • For the application process to be completed, a minimum of three (3) 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:

  • Refer to the provider type 'Health Maintenance Organization (HMO)'
Medicare Only Providers

Provider Type: 90

Specialty: Histocompatibility Laboratory
Specialty Code: 890

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes

 

Specialty: Home Infusion Therapy Supplier
Specialty Code: 891

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Accreditation as a Home Infusion Therapy Supplier
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes



Specialty: Independent Diagnostic Testing Facility
Specialty Code: 897

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Copy of the License for the Supervising Physician
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes



Specialty: Mammography Screening Center
Specialty Code: 893

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Food and Drug Administration (FDA) valid provisional certificate or valid certificate as a Mammography Screening Center.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes

 

Specialty: Medicare Diabetes Prevention Program Supplier
Specialty Code: 895

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Medicare Diabetes Prevention Program (MDPP) preliminary recognition (as defined at 42 CFR § 424.205(c)(1)) or full recognition as determined by the Center for Disease Control and Prevention's (CDC) Diabetes Prevention Recognition Program (DPRP).
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:HighFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes

 

Specialty: Medicare Only Hospital
Specialty Code: 892

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Clinical Laboratory Improvement Amendments (CLIA) certificate
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes

 

Specialty: Opioid Treatment Program
Specialty Code: 898 High Risk depending on Substance Abuse and Mental Health Services Administration (SAMHSA) certification
                            896 Moderate Risk depending on SAMHSA certification

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • SAMHSA certification for an Opioid Treatment Program
    • Not fully and continuously certified since 10/24/2018 = high risk level.
    • Fully and continuously certified since 10/24/2018 = moderate risk level.
  • Taxonomy 261QM2800X Clinic/Center - Methadone Clinic is required.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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 or Moderate depending on SAMHSA CertificationFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes

 

Specialty: Religious Non-Medical Health Care Institution
Specialty Code: 894

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes
Non-Physician Practitioner - Group

Provider Type: 25
Specialty: Non-Physician Practitioner - Group
Specialty Code: 441
OR
Specialty: Telemedicine
Specialty Code: 878

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 or Audiologist.
  • 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Each service location must complete a separate application.
    • The Non-Physician Practitioner Group specialty must enter a physical address for the service location address in the application.
    • The Telemedicine specialty may list a PO Box for the service location address in the application. (Please enter the PO Box in one of the following accepted formats: Box XXXX, PO XXXX, Post Office XXXX or POB XXXX.)
  • Electronic Visit Verification (EVV) is optional with this specialty 441. (Not required for specialty 878.) To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
  • Only one of these specialties may be active at a time.
  • The Telemedicine specialty is excluded from participation as a Primary Care Medical Provider (PCMP).

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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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.
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

Required Attachments:

  • License
  • RN Supervision Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)

 

Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?Yes (396), No (382, 392)OOS Allowed?RestrictedBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?RestrictedBT 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
OR
Billing Individual - bills directly for themselves

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information..

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed? YesBT Allowed?Yes
Optical Outlet

Provider Type: 08
Specialty: Optical Outlet
Specialty Code: 395

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
    • Active-duty military physicians providing services as part of official duties to Medicaid members at a military facility may have a license from another state and are not required to have a Colorado 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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • This provider type is only for pediatric personal care benefit members. Refer to the Pediatric Personal Care Billing Manual 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). Visit the EVV web page for additional information.

Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:HighFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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), Indian Health Services (IHS) Pharmacy (PT 62), Federally Qualified Health Center (PT 32) or Clinic - Practitioner (PT 16); may affiliate to multiple pharmacies and/or practitioner clinics on one enrollment application (if applicable).
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

OR Specialty: Pharmacy
Specialty Code: 461

Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

OR Specialty: Pharmacy with DME
Specialty Code: 462

Risk Level:HighFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes

OR Specialty: Rural Dispensing Physician Site
Specialty Code: 463

Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes

Enrollment Type: Facility

  • Each pharmacy service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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.
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:ModerateFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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

Required Attachments:

  • License
    • Active-duty military physicians providing services as part of official duties to Medicaid members at a military facility may have a license from another state and are not required to have a Colorado 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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring – limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • License
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

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, Office of Early Childhood, Division of Early Care and Learning, Time Limited Child Care License indicating Service Type as: Residential Child Care Facility. (Required for in-state providers only.)
  • Department of Human Services, Behavioral Health Administration (BHA) (previously known as the Office of Behavioral Health) Attestation Letter (Required for in-state providers only.)
  • Psychiatric Residential Treatment Facilities (PRTFs) 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Psychologist - Bachelors

Special Instructions:

  • Per 10 CCR 2505-10, Colorado Medicaid cannot enroll a Psychologist who does not meet Masters- or Doctorate-level education requirements.
Qualified Residential Treatment Program

Provider Type: 68
Specialty: Qualified Residential Treatment Program (QRTP)
Specialty Code: 689

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • A QRTP cannot be enrolled as a Residential Child Care Facility (RCCF-provider type 52) at the same time.

Required Attachments:

  • Department of Human Services, Office of Early Childhood, Division of Early Care and Learning, Time Limited Child Care License indicating Service Type as: Qualified Residential Treatment Program.
  • Accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or Council on Accreditation of Services for Families and Children.
  • Attestation Form for Facilities Enrolling with Health First Colorado (RCCF & QRTP), located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, must be completed and attached for in state only.
  • W9 (signed and dated within the last 6 months).
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?No
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Registered Nurse

Special Instructions:

  • Refer to Non-Physician Practitioner - Individual
Rehabilitation Agency

Provider Type: 48
Specialty: Practitioner
Specialty Code: 397

Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

OR Specialty: Comprehensive Outpatient Rehabilitation Facility
Specialty Code: 470

Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

Required Attachments:

  • Copy of the individual license for the individual provider mentioned above who will affiliate to the group.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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

  • A Residential Child Care Facility (RCCF) cannot be enrolled as a Qualified Residential Treatment Program (QRTP - Provider Type 68) at the same time as an RCCF enrollment.
  • 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Department of Human Services, Office of Early Childhood, Division of Early Care and Learning, Time Limited 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 clinic
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT 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 and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes
School Health Services

Provider Type: 51
Specialty: School Health Services
Specialty Code: 475

Enrollment Type: Facility

  • Each school district must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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. Indicate "CFO" or "Superintendent" following the listed individual's name.

Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?No
School Speech Therapist

Provider Type: 42
Specialty: School Health Services
Specialty Code: 777

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

  • Individuals complete only one enrollment application and must affiliate to at least one enrolled School Health Services organization. Multiple affiliations can be indicated in the application when applicable. (Affiliations to other groups/clinics are not acceptable.)
  • Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

  • Colorado Department of Education (CDE) License with a Speech Therapist Endorsement. (Attach a copy of current license and complete the license information.)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT 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, Prescribing, Referring - limited to Ordering/Prescribing/Referring

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

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 the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes
Substance Use Disorder (SUD) Continuum

Provider Type: 64
 

SpecialtySpecialty Code
ASAM Level 2.5 Partial Hospitalization Program (PHP)212
ASAM Level 1.0371
ASAM Level 1 WM372
ASAM Level 2.1 IOP373
ASAM Level 2 WM374
ASAM Level 3.1871
ASAM Level 3.3872
ASAM Level 3.5873
ASAM Level 3.7874
ASAM Level 3.2 WM875
ASAM Level 3.7 WM876

 

Enrollment Type: Facility

  • Each location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Individual licensed practitioners must enroll separately.
  • When applicable, out-of-state or bordering town locations must contract with a Regional Accountable Entity for single case agreements.

Required Attachments:

  • Department of Human Services Behavioral Health Administration (BHA) license with each appropriate ASAM level indicated.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:LimitedFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?Not allowed for ASAM Levels 2.5 PHP, 1.0, 1 WM, 2.1 IOP or out-of-state 2 WM

Allowed for ASAM Levels 3.1, 3.2 WM, 3.3, 3.5, 3.7 & 3.7 WM		BT Allowed?Yes

 

SpecialtySpecialty Code
ASAM Level 1.7 Opioid Treatment Provider (OTP) 
Fully and continuously SAMSHA certified since 10/23/2018. 
Moderate Risk		213
ASAM Level 1.7 Opioid Treatment Provider (OTP) 
Not fully and continuously SAMSHA certified since 10/23/2018. 
High Risk		214

Enrollment Type: Facility

  • Each location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Individual licensed practitioners must enroll separately.
  • When applicable, out of state or bordering town locations must contract with a Regional Accountable Entity for single case agreements.

Required Attachments:

  • Department of Human Services Behavioral Health Administration (BHA) license with ASAM Level 1 WM indicated.
  • Department of Human Services Behavioral Health Administration (BHA) license for a Controlled Substance Provider.
  • SAMHSA certification for an Opioid Treatment Program
    • Fully and continuously certified since 10/23/2018 = moderate risk level.
    • Not fully and continuously certified since 10/23/2018 = high risk level.
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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 or Moderate depending on SAMHSA CertificationFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?NoBT Allowed?Yes

 

Specialty: Substance Use Disorder-Clinics
Specialty Code: 477

Effective August 1, 2024, no new enrollments are allowed for Specialty 477 Substance Use Disorder-Clinics.

Specialty: Special Connections
Specialty Code: 870

Effective January 1, 2024, no new enrollments are allowed for Special Connections.

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.
  • Must enroll using the individual's Social Security Number (SSN).
  • 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 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) benefit manager at Haylee.Rodgers@state.co.us prior to submitting an enrollment application. 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
      • Screenprint from the accreditation agency's website
  • Sales Tax License 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)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, 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:HighFee Req'd? NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?ConditionalBT 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
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
  • 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 Haylee.Rodgers@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
      • Screenprint from the accreditation agency's website
  • Sales Tax License 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:HighFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?ConditionalBT 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
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
  • 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 Haylee.Rodgers@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
      • Screenprint from the accreditation agency's website
  • Sales Tax License 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:HighFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?ConditionalBT 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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

Specialty: County Agency, Non Metro Area
Specialty Code: 124

Enrollment Type: Facility

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Ambulance License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?NoNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

Specialty: Emergency
Specialty Code: 324

Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate application fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

Required Attachments:

  • Ambulance license
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?NoOOS Allowed?YesBT Allowed?Yes

 

Provider Type: 73 - Non-Emergent Medical Transportation
The state has imposed a moratorium on new enrollments for non-emergency medical transportation due to a significant potential for fraud, waste, or abuse to the Medicaid program in accordance with 42 CFR 455.470.  The moratorium of six months on new enrollments approved by CMS, effective April 1, 2024, for Non-Emergent Medical Transportation (NEMT) has been extended for another six months effective October 1, 2024.
 

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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • 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 the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
Risk Level:ModerateFee Req'd?YesNPI Req'd?Yes
Medicare Req'd?YesOOS Allowed?YesBT Allowed?Yes