Find Your Provider Type | Department of Health Care Policy and Financing

Enrollment requirements will vary based on the provider type and enrollment type.

Providers will choose both a provider type and an enrollment type when submitting an application. Providers can learn more about enrollment types by clicking on the "Continue to Enrollment Type" button at the bottom of this web page.

Provider Type describes the types of service that will be rendered.

The provider type may be required to pay an application fee as required by Federal regulation.

Terms and Definitions

Risk Level:

Each provider type has been designated limited, moderate, or high risk.

Limited: These providers must meet all Federal/State requirements and pass all license and certification verifications and database checks.
Moderate: These providers must meet all of the "Limited" requirements and also host a site visit at the service location address.
High: These providers must meet all of the "Moderate" requirements and also submit to fingerprint criminal background checks.

Border town:

Some provider types allow enrollment when the service location is in an approved Border Town. See Appendix F for a list of approved border towns.

A list of allowable provider types for enrollment are shown below. Click on the provider types for more enrollment details. Home and Community-Based Services (HCBS) are only for members who have a waiver benefit plan. HCBS is provider type 36.

Enrollment Information for Home and Community-Based Services Providers

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required?	No	NPI Required?	No
Medicare Required?	No	Out of State Allowed?	Yes	Border Town 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 six [6] months).
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	Yes - with proof of a Colorado License

Behavioral Health Admin Service Organization

Provider Type: 67

Specialty: BHASO
Specialty Code: 778

Enrollment Type: Atypical

A contract with the Behavioral Health Administration as a Behavioral Health Administrative Service Organization (BHASO) is required.
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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required?	No	NPI Required?	No
Medicare Required?	No	Out of State Allowed?	No	Border Town Allowed?	No

Behavioral Health ASO

THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS AS OF January 1, 2025. The Behavioral Health ASO (provider type [PT] 91) is being replaced by the Behavioral Health Administrative Service Organization (PT 67). Please review the requirements indicated for the Behavioral Health Administrative Service Organization.

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:	Limited	Fee Required	No	NPI Required	No
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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:

Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) Acute Treatment Unit (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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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:

Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) Crisis Stabilization Unit (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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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 Behavioral Health Administration (BHA) Behavioral Health Entity (BHE)
License with 'Outpatient Emergency/Crisis Endorsement' listing 'Mobile'.
and/or
BHA approval for an Essential Safety Net Provider with 'Emergency and Crisis
Behavioral Health Services' listing 'Mobile'.
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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	No

Behavioral Health Group

Provider Type:77

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

Important: Do not select this provider type if billing for medical services only. Enroll as PT 77 if providing behavioral health services only.

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 (1) Physician (Provider Type [PT] 05), Osteopath (PT 26), Physician Assistant (PT 39) or Nurse Practitioner (PT 41) AND at least one (1) Licensed Psychologist (PT 37) or Licensed Behavioral Health Clinician (PT 38) who will affiliate with the group. (There must be two (2) copies of licenses attached with the application, one (1) for the Physician, Osteopath, Physician Assistant or Nurse Practitioner AND one (1) 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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	With Prescriber = Yes Without Prescriber = No	Border Town Allowed?	Yes

Behavioral Health MSO

THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS AS OF January 1, 2025. The Behavioral Health MSO (provider type [PT] 92) is being replaced by the Behavioral Health Administrative Service Organization (PT 67) . Please review the requirements indicated for the Behavioral Health Administrative Service Organization.

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	No
Medicare Required	No	Out of State Allowed?	No	Border Town 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 group provider offering psychotherapy services for mental health or substance use disorder conditions do not select this provider type. Refer to the information for Substance Use Disorder (SUD) Continuum (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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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

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.

Important: If you are a licensed clinician providing psychotherapy services for mental health or substance use disorder conditions do not select this provider type. Refer to the 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 (1) 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 and/or a PT/OT/SLP Pediatric 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Copy of the individual license for the Certified Nurse Midwife (CNM) or Physician who will affiliate to the Birthing Center
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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:	Limited	Fee Required	No	NPI Required	No
Medicare Required	No	Out of State Allowed?	No	Border Town 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:

Completed Case Management Agency Application specifically for TCM Transition Coordination
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
- Address must match one (1) address listed on the application.
- DBA (Trade Name) must be listed on Line 2 if included on the application.
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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 (6) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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 six [6] months).
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 individual dentists and dental hygienists.
Dental clinics must be owned by one (1) of the following entities per 12-220-303, C.R.S.:
- 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
- For political subdivisions and non-profit corporations, the affiliating individual's dental license is preferred but not required as an attachment.
Certificate of Good Standing issued by the Colorado Secretary of State for a non-profit corporation only
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 (1) 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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	No

Specialty: Supportive Housing Provider
Specialty Code: 208

Enrollment Type: Group

Must have at least one (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months). hs)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 (2) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	No	Border Town 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 (1) enrollment application and must affiliate to at least one (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months).
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	High	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Durable Medical Equipment (DME)

Special Instructions:

Refer to 'Supply Facility', 'Supply Billing Individual', or 'Pharmacy (Pharmacy with DME)'.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit Provider Group

Provider Type: A3

Specialty: Chiropractic Group
Specialty Code: 225

Enrollment Type: Group

Must enroll using the organization's federal Employer Identification Number (EIN).
Each service location must complete a separate application.
For new enrollments, the group must be approved prior to enrollment of the individual chiropractors.
Affiliating individuals are restricted to EPSDT chiropractors and there must be at least one Chiropractor that will affiliate with the group.
Credentialed chiropractors must be enrolled independently (separate application) and affiliated with the group.

Required Attachments:

Copy of the license for the chiropractor affiliating with the group.
W9 (signed and dated within the last 6 months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	No	Border Town Allowed?	Yes

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Chiropractor

Provider Type: A4

Specialty: EPSDT Chiropractor
Specialty Code: 226

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

This provider type is for Chiropractors for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 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).
EPSDT Chiropractors may only affiliate with the EPSDT Benefit Group with specialty Chiropractic Group.

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 (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	No	Border Town Allowed?	Yes

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes (Only for Specialties 150 and 160)	Border Town 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 (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level	Limited	Fee Required	No	NPI Required	Yes-HMO/PACE-393, No-HMO-391
Medicare Required	No	Out of State Allowed?	No	Border Town 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 Level	Limited	Fee Required	No	NPI Required	No
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	No

High-Intensity Pediatric Residential Treatment

Provider Type: 30
Specialty: Psychiatric Residential Treatment Facility (CO) (In-state only)
Specialty Code: 227

Enrollment Type: Facility

This specialty is for in-state Psychiatric Residential Treatment Facilities only.
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.
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, Behavioral Health Administration (BHA) Attestation Letter.
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 (opens in new window) and in federal law.
W9 (signed and dated within the last 6 months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	No

Specialty: Out-of-State High-Intensity Residential Treatment
Specialty Code: 476

Enrollment Type: Facility

This specialty is for out-of-state high-intensity residential treatment facilities only, who are not Qualified Residential Treatment Programs (QRTPs).
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:

Out-of-state high-intensity residential treatment facilities located in another state must submit all license and certification requirements as applicable to 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 facility is in compliance with the condition of participation for Restraint and Seclusion as described in 10 CCR 2505-10 Section 8.765.6.F (opens in new window) and in federal law.
W9 (signed and dated within the last 6 months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Home & Community Based Services (HCBS)

Provider Type: 36 Special Instructions:

Click here for Information by HCBS Service Provided

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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: Out of State Pharmacy Questionnaire is no longer required. The Out of State 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Lactation Consultant

Provider Type: 70

Specialty: Lactation Consultant
Specialty Code: 215

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

Required Attachments:

A copy of the Certified International Board-Certified Lactation Consultant (IBCLC) with current certification by the International Board of Lactation Consultant Examiners (IBLCE) must be attached, and the data must be entered in the certification panel.
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 six [6] months).
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	High	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Lactation Counselor or Educator

Provider Type: 71

Specialty: Lactation Counselor or Educator
Specialty Code: 216

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

Individuals complete only one (1) enrollment application; multiple affiliations can be indicated in the application when applicable.
Must enroll using the individual's Social Security Number (SSN).

Required Attachments:

A copy of the appropriate certification must be attached, and the data must be entered in the certification panel.
- Certified Lactation Counselor (CLC) with current certification by the Academy of Lactation Policy and Practice, Inc. (ALPP)
  OR
- Certified Lactation Educator (CLE) with current certification by the Childbirth and Postpartum Professional Association (CAPPA)
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Lactation/Doula Professional Group

Provider Type: 72

Specialty: Lactation/Doula Group
Specialty Code: 217

Enrollment Type: Group

There must be at least one (1) Lactation Consultant (IBCLC) or Doula affiliated with the group.
For new enrollments, the group must be approved prior to enrollment of the rendering individuals.
The rendering individuals must be enrolled independently (separate application) and affiliated with the group.
Must enroll using the organization's federal Employer Identification Number (EIN).
Each service location must complete a separate application.

Required Attachments:

Copy of the Lactation Consultant (IBCLC) certification or the Doula Provider Attestation Form for the affiliating individual.
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 Individuals Only:

W9 (signed and dated within the last six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) for the organization (either a Clinic-Practitioner or a Non-Physician Practitioner-Group)
2. One (1) for an individual enrollment for the supervising MD/DO (Clinic-Practitioner) or NP (Non-Physician Practitioner-Group)
3. One (1) 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-Emergent 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	No	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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 Certification	Fee Required	No	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Non-Physician Practitioner - Group

Provider Type: 25
Specialty: Non-Physician Practitioner - Group (For in-person and telehealth services.)
Specialty Code: 441
OR
Specialty: Telemedicine (For telehealth services only.)
Specialty Code: 878

Enrollment Type: Group

Important: If you intend on billing for services covered under the Pediatric Behavioral Therapies Billing Manual do not select this provider type for enrollment. Refer to the information for Behavioral Therapy - Clinic (83) instead.

Must have at least one (1) of the following provider types who will affiliate to the group: Licensed Behavioral Health Clinician (ACD/LAC, CSW, LPC, or MFT), 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 (1) 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 (1) 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 individual provider mentioned above who will affiliate to the Group
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months). )

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Nurse-Midwife

Provider Type: 22
Specialty: Nurse-Midwife
Specialty Code: 080

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Nursing Facility

Provider Type: 20

Specialty: Nursing Facility - Hospital Back Up Program
Specialty Code: 382

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Restricted	Border Town Allowed?	Yes

Specialty: Nursing Facility - Regular
Specialty Code: 392

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Restricted	Border Town Allowed?	Yes

Specialty: Nursing Facility - Swing Beds
Specialty Code: 396

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Restricted	Border Town Allowed?	Yes

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Restricted	Border Town 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Optometrist

Provider Type: 07
Specialty: Optometrist
Specialty Code: 183

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Osteopath

Provider Type: 26
Specialty: Osteopath
Specialty Code: 501

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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 (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Pharmacy

Provider Type: 09

ATTENTION ALL PHARMACIES! In order to bill any type of Durable Medical Equipment and Supplies (DME) to Medicaid, you must also select the specialty type "Pharmacy with DME" on your provider application. That specialty type is required even if your pharmacy qualifies for the Medicare exemption from DME accreditation. If you select any other pharmacy specialty, your pharmacy will not be able to bill any DME to Medicaid. Please be advised that "Pharmacy with DME" is a high-risk level specialty that is subject to additional screening requirements.

Specialty: Mail Order
Specialty Code: 460

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

OR Specialty: Pharmacy
Specialty Code: 461

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

OR Specialty: Pharmacy with DME
Specialty Code: 462

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	Yes

OR Specialty: Rural Dispensing Physician Site
Specialty Code: 463

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Moderate	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Physical Therapist/Occupational Therapist/Speech-Language Pathologist (PT/OT/SLP) - Pediatric Behavioral Therapy Clinic

Provider Type: 15

Specialty: Outpatient Therapies PBT Clinic
Specialty Code: 220

Enrollment Type: Group

Must have at least one enrolled Behavioral Therapist, Occupational Therapist, Physical Therapist, Speech Therapist affiliated with the group. Affiliations are restricted to Behavioral Therapist (provider type 84), Occupational Therapist (provider type 28), Physical Therapist (provider type 17) and Speech Therapist (provider type 27).
The group must enroll using the organization's federal Employer Identification Number (EIN).
Each service location must complete a separate application.
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.
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:

A completed Behavioral Therapy Provider Attestation Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, for the individual therapist who will affiliate with the group. Attach evidence of license, credential, training and/or experience as indicated in the form.
W9 (signed and dated within the last 6 months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	No	Border Town Allowed?	Yes

Physician

Provider Type: 05
Specialty: Physician
Specialty Code: 505

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Podiatrist

Provider Type: 06
Specialty: Podiatrist
Specialty Code: 194

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months).
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Re-entry Services Provider

Provider Type: 59

Specialty: Local Facility
Specialty Code: 218
OR
Specialty: State Facility
Specialty Code: 219
OR
Specialty Code: In-reach Provider
Specialty Code: 228

Enrollment Type: Group

Must enroll using the organization's federal Employer Identification Number (EIN).
Each service location must complete a separate application.
Must have at least one enrolled behavioral health provider (provider type 37 Licensed Psychologist and/or 38 Licensed Behavioral Health Clinician) 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 group.

Required Attachments:

Copy of the individual license for the behavioral health provider who will affiliate to the group.
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required?	No	NPI Required?	Yes
Medicare Required?	No	Out of State Allowed?	No	Border Town Allowed?	No

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	No
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Registered Nurse

Special Instructions:

Refer to Non-Physician Practitioner - Individual

Rehabilitation Agency

Provider Type: 48
Specialty: Practitioner
Specialty Code: 397

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

OR Specialty: Comprehensive Outpatient Rehabilitation Facility
Specialty Code: 470

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Enrollment Type: Group

Practitioner specialty must have at least one (1) enrolled, licensed physical, occupational or speech therapist affiliated with the group.
Comprehensive Outpatient Rehabilitation Facility specialty must have at least one (1) enrolled, licensed practitioner (MD, DO) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 (1) 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).
Only one (1) specialty may be active at each service location address. (Duplicate enrollments for a Rural Health Clinic at the same service location address are not allowed.)

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town 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.

Required Attachments:

W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town 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 (1) enrollment application and must affiliate to at least one (1) 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:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	No

Speech Therapist

Provider Type: 27
Specialty: Speech Therapist
Specialty Code: 452

Complete only one (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Substance Use Disorder (SUD) Continuum

Provider Type: 64

Specialty	Specialty Code
ASAM Level 2.5 Partial Hospitalization Program (PHP)	212
ASAM Level 1.0	371
ASAM Level 1 WM	372
ASAM Level 2.1 IOP	373
ASAM Level 2 WM	374
ASAM Level 3.1	871
ASAM Level 3.3	872
ASAM Level 3.5	873
ASAM Level 3.7	874
ASAM Level 3.2 WM	875
ASAM Level 3.7 WM	876

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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Limited	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State 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	Border Town Allowed?	Yes

Specialty	Specialty 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [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 Certification	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	No	Border Town Allowed?	Yes

Specialty: Substance Use Disorder-Clinics
Specialty Code: 477

Effective July 1, 2025, this specialty is no longer available.

Specialty: Special Connections
Specialty Code: 870

Effective January 1, 2024, this specialty is no longer available.

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 (1) 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 HCPF_DME@state.co.gov 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 (1) 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 six [6] months)
Voided check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Conditional	Border Town 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 HCPF_DME@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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months)
Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Conditional	Border Town 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 HCPF_DME@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 (1) 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	High	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Conditional	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	No	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town 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 six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	No	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Provider Type: 73 - Non-Emergent Medical Transportation
The state has imposed a moratorium on new enrollments for Non-Emergent Medical Transportation (NEMT) due to a significant potential for fraud, waste or abuse to the Medicaid program in accordance with 42 CFR 455.470. An extension of at least six (6) months was requested and approved by the Centers for Medicare & Medicaid Services (CMS), and will be in effect until at least March 31, 2026.

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. Out of State must submit similar document or X-ray license from own state.
W9 (signed and dated within the last six [6] months)
Voided business check (must be preprinted and cannot be handwritten, no temporary checks or deposit slips) or bank letter (must be signed by a bank representative and dated within the last six [6] months).
Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

Risk Level:	Moderate	Fee Required	Yes	NPI Required	Yes
Medicare Required	Yes	Out of State Allowed?	Yes	Border Town Allowed?	Yes

Continue to Enrollment Type