Provider Type Information for Revalidation

Revalidation Information by Provider Type

The federal regulation at 42 CFR § 455.414 requires that state Medicaid agencies revalidate the enrollment of all providers, regardless of provider types, at least every 5 years.

When revalidating businesses (EIN enrollment) that have more than one service location, a separate revalidation for each different location is required.

If a fee is required, it is applicable to each service location. Please review the Provider Type information below to determine if the fee is required.

Individuals (SSN enrollment) complete only one revalidation regardless of the number of affiliated groups. (If an individual MD, nurse, PA, PT, etc., is revalidated by an authorized agent, only one revalidation can be completed.)

Waiver service providers select the Home and Community-Based Services (HCBS) provider type for revalidation requirements.

Before beginning a revalidation through the Provider Portal, please take a minute to review the:

After reviewing the training materials, log into the Provider Web Portal to begin revalidation.

Terms and Definitions

RISK LEVEL

Each provider type is designated low, moderate, or high risk.

FEE REQ'D?
The provider type is required to pay a fee as required by Federal regulation.

NPI REQ'D?
The provider is required to have a National Provider Identifier (NPI).

MEDICARE REQ'D?
The provider type is required to be an approved Medicare provider.

OOS ALLOWED?
(Out-of-state (OOS) enrollment allowed?) The provider type allows for out-of-state service locations.

BT ALLOWED?
(Border town (BT) enrollment allowed?) the provider type allows the service location to be in an approved border town. Please see Appendix F for a list of approved border towns.

 

Provider Types

Click on the provider types below for more revalidation details.

Administrative Services Organization (ASO)
Specialty: Transportation
Specialty Code: 810
OR
Specialty: Dental
Specialty Code: 811
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Ambulatory Surgery Center (ASC)
Specialty: Ambulatory Surgery Center
Specialty Code: 300
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Audiologist
Specialty: Audiologist
Specialty Code: 310
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
REQUIRED Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes - with proof of a Colorado License
Behavioral Therapy - Clinic
Specialty: Behavioral Therapy Clinic
Specialty Code: 830
  • Each service location must complete a separate revalidation
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Behavioral Therapy - Individual
Specialty: Behavioral Therapist
Specialty Code: 831
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
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 Formmust be completed
    • Evidence of license, credential, training and/or experience must be included
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Billing Agent
THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR ENROLLMENTS. A Trading Partner ID (TPID) is required to submit batch claims or batch eligibility files. Visit the Trading Partner page for additional information regarding TPIDs.
Birthing Center
Specialty: Free Standing Birthing Center
Specialty Code: 116
  • Each service location must complete a separate revalidation.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Copy of the individual license for the Certified Nurse Midwife (CNM) or Physician who is affiliated to the Birthing Center.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Case Management Agency
Specialty: Contracted Case Management
Specialty Code: 330
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No BT Allowed? No

 

Specialty: Targeted Case Management/Transition Services (TCM/TS)
Specialty Code: 770
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Certified Registered Nurse Anesthetist (CRNA)
Specialty: Certified Registered Nurse Anesthetist (CRNA)
Specialty Code: 340
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Clinic - Dental
Specialty: Clinic - Dental
Specialty Code: 350‚Äã
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Copy of the license of the dentist or dental hygienist who owns the clinic, or copy of the Certificate of Good Standing issued by the Colorado Secretary of State if owned by a non-profit corporation.

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Clinic - Practitioner
Specialty: Clinic - Practitioner
Specialty Code: 351
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Copy of the individual license for the MD, DO, OD or DPM who is affiliated to the clinic

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Community Clinic
Specialty: Community Clinic or Community Clinic & Emergency Center
Specialty Code: 860
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License as a Community Clinic or Community Clinic & Emergency Center(attach a copy of current license and complete the license information in revalidation)
  • Affiliation Addendum to the Hospital license showing the service location address is affiliated to a certain hospital
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Community Mental Health Center
Specialty: Community Mental Health Center
Specialty Code: 360
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Colorado Department of Public Health and Environment license as a Behavioral Health Entity. (attach a copy of current license and complete the license information in revalidation)
  • Colorado Department of Human Services, Office of Behavioral Health license as a Community Mental Health Center. (attach a copy of current license and complete the license information in revalidation)
  • Copy of the individual license for the Physician, Osteopath, Licensed Behavioral Health Clinician, or Licensed Psychologist who is affiliated to the clinic.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Dental Hygienist
Specialty: Dental Hygienist
Specialty Code: 066
  • Complete only one revalidation for an individual regardless of the number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Dentist
Specialty: Oral Surgery
Specialty Code: 061
OR Specialty: Dentist
Specialty Code: 062
OR Specialty: Orthodontist
Specialty Code: 063
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License -Two separate licenses required - Dental and Physician for Oral Surgery specialty ONLY(attach a copy of current license and complete the license information in revalidation)
    • 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(attach a copy of current license and complete the license information in revalidation)
  • 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.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Developmental Evaluation Clinic
Specialty: Developmental Evaluation Clinic
Specialty Code: 370
  • Each location must complete a separate revalidation.
Required Attachments:
  • License(attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Dialysis Center
Specialty: Dialysis Center
Specialty Code: 375
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? No BT Allowed? Yes
Family Planning Clinic
THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR ENROLLMENTS. Family planning services currently may be provided under the Clinic - Practitioner or Non-Physician Practitioner - Group, provider types. Please review those provider type requirements to select the appropriate entity based on your credentialed professionals.

 

Federally Qualified Health Center
Specialty: Freestanding
Specialty Code: 150
OR Specialty: Hospital Based
Specialty Code: 160
OR Specialty: Denver Health and Hospital School Based Clinics
Specialty Code: 199
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? (Only for Specialties 150 and 160) BT Allowed? Yes (Only for Specialties 150 and 160)
Foreign Teaching Physician
Specialty: Foreign Teaching Physician
Specialty Code: 500
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Health Maintenance Organization (HMO)/Preferred Provider Organization (PPO)
Specialty: Health Maintenance Organization (HMO)
Specialty Code: 391
OR Specialty: Health Maintenance Organization (HMO)/PACE
Specialty Code: 393 
Specialty: D-SNP HMO/PPO
Specialty Code: 400
  • Each service location must complete a separate revalidation.
Required Attachments:
  • License from the Colorado Division of Insurance - Required for HMO Specialty 391 and D-SNP HMP/PPO Specialty 400.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes-HMO/PACE-393,
No-HMO-391, D-SNP 400
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Home & Community-Based Services (HCBS)
Special Instructions:
Home Health
Specialty: Home Health
Specialty Code: 385
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospice
Specialty: Hospice
Specialty Code: 390
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (License must include the service location address.Attach a copy of current license and complete the license information in revalidation.)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospital - General
Specialty: Hospital - General
Specialty Code: 301
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
  • License (License must include an address that matches the service location address on file. Attach a copy of current license and complete the license information in revalidation.)
    • If this is an Off Campus Location (OCL), attach the hospital license and OCL addendum showing the matching service location address (including suite number if applicable). CLIA may be waived if this OCL does not do laboratory testing.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Hospital - Mental
Specialty: Hospital - Mental
Specialty Code: 302
  • Each service location must complete a separate revalidation and pay a separate application fee.
Required Attachments:
  • License (License must include an address that matches the service location address on file. Attach a copy of current license and complete the license information in revalidation.)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? No BT Allowed? No
Independent Laboratory
Specialty: Independent Laboratory
Specialty Code: 410
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Indian Health Services - FQHC
Specialty: Indian Health Services
Specialty Code: 170
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • 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 Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Indian Health Services - Pharmacy
Specialty: Indian Health Services
Specialty Code: 420
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Licensed Behavioral Health Clinician
Specialty:Licensed Behavioral Health Clinician
Specialty Code: 521
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (ACD/LAC, CSW, LPC, or MFT) (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Licensed Psychologist
Specialty: Licensed Psychologist (PhD, PsyD, EdD)
Specialty Code: 520
  • Complete only one revalidation regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed?Yes BT Allowed? Yes
Non-Physician Practitioner - Group
Specialty: Non-Physician Practitioner - Group
Specialty Code: 441
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Copy of the individual license/certification/attestation form for the individual provider who is affiliated to the group. (Acceptable licenses include: Behavioral Health Clinician, Psychologist, Nurse Practitioner, Nurse Midwife, Certified Registered Nurse Anesthetist, Physical Therapist, Occupational Therapist, Speech Therapist, Audiologist, or Behavioral Therapist. NOTE: Behavioral Therapists must submit either BCBA certification or Behavioral Therapy Attestation Form.)

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Non-Physician Practitioner - Individual
Specialty: Non-Physician Practitioner - Individual
Specialty Code: 440
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • RN Supervision form
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
Nurse Practitioner
Specialty: Pediatric
Specialty Code: 034
AND/OR Specialty: Family
Specialty Code: 035
AND/OR Specialty: General
Specialty Code: 335
  • Complete only one revalidation for an individual regardless of the number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Nurse-Midwife
Specialty: Nurse-Midwife
Specialty Code: 080
  • Complete only one revalidation for an individual regardless of the number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Nursing Facility
Specialty: Nursing Facility - Hospital Back Up Program
Specialty Code: 382
OR Specialty: Nursing Facility - Regular
Specialty Code: 392
OR Specialty: Nursing Facility - Swing Beds
Specialty Code: 396
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability Insurance (attach a copy of current insurance and complete the insurance information in revalidation)
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes (396), No (382, 392) OOS Allowed? Restricted BT Allowed? Yes
Nursing Facility - ICF/IID
Specialty: ICF/IID - Private
Specialty Code: 383
OR Specialty: ICF/IID - State
Specialty Code: 394
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability Insurance (attach a copy of current insurance and complete the insurance information in revalidation)
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Restricted BT Allowed? Yes
Occupational Therapist
Specialty: Occupational Therapist
Specialty Code: 450
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed?Yes BT Allowed? Yes
Optical Outlet
Specialty: Optical Outlet
Specialty Code: 395
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed?Yes
Optometrist
Specialty: Optometrist
Specialty Code: 183
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Osteopath
Specialty: Osteopath
Specialty Code: 501
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
    • 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.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Personal Care Agency
Specialty: Personal Care Agency
Specialty Code: 560
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Pharmacist
Specialty: Pharmacist
Specialty Code: 750
  • Complete only one revalidation for an individual regardless of number of affiliated pharmacies.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Pharmacy
Specialty: Mail Order
Specialty Code: 460
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Pharmacy
Specialty Code: 461
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Pharmacy with DME
Specialty Code: 462
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
OR Specialty: Rural Dispensing Physician Site
Specialty Code: 463
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
  • Each pharmacy service location must complete a separate revalidation.
  • Pharmacy with DME-(specialty code 462) must pay a fee with each revalidation.
Required Attachments:
  • Colorado Pharmacy License (Specialty 463 ONLY-license may be from other state if in a border town). Attach a copy of current license and complete the license information in revalidation.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Physical Therapist
Specialty: Physical Therapist
Specialty Code: 451
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Physician
Specialty: Physician
Specialty Code: 505
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
    • 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.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Physician Assistant
Specialty: Physician Assistant
Specialty Code: 510
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Podiatrist
Specialty: Podiatrist
Specialty Code: 194
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Psychiatric Residential Treatment Facility
Specialty: Psychiatric Residential Treatment Facility
Specialty Code: 476
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Department of Human Services - Division of Child Welfare License as a Psychiatric Residential Treatment Facility (Required for in-state providers only)
  • Department of Human Services - Division of Child Welfare License as a Residential Child Care Facility (Required for in-state providers only)
  • Department of Human Services, Office of Behavioral Health Attestation Letter (Required for in-state providers only)
  • Psychiatric Residential Treatment Facility located in another state must submit all license and certification requirements for a PRTF in the state in which it is located.
  • Accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.
  • Provide an attestation indicating the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in 10 CCR 2505-10 Section 8.765.6.F and in federal law.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
QMB Benefits Only
Specialty: QMB Benefits Only - Chiropractors
Specialty Code: 321
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
Qualified Residential Treatment Program
Specialty: Qualified Residential Treatment Program (QRTP)
Specialty Code: 689
  • Each service location must complete a separate revalidation.
  • 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 – Division of Child Welfare License as a QRTP.
  • 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 must be completed and attached for in state only.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Regional Accountable Entity (RAE)
Specialty: Regional Accountable Entity
Specialty Code: 850
  • Each region must complete a separate revalidation.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
  • Colorado Division of Insurance specifically for either:
    • Health Maintenance Organization (HMO), OR
    • Limited Service Licensed Provider Network (LSLPN)
Risk Level: Limited Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Rehabilitation Agency
Specialty: Practitioner
Specialty Code: 397
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
OR Specialty: Comprehensive Outpatient Rehabilitation Facility
Specialty Code: 470
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes
  • Each service location must complete a separate revalidation and pay a separate fee.
  • Comprehensive Outpatient Rehabilitation Facility must pay a separate fee with each revalidation.
Required Attachments:
  • Copy of the license of the Physical, Occupational, or Speech Therapist who is affiliated with the group (397)

  • Copy of the individual license of the MD, DO, OD or DPM who is affiliated with the group (470)

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Residential Child Care Facility
Specialty: Mental Health Program
Specialty Code: 471
  • Each service location must complete a separate revalidation.
  • An RCCF cannot be enrolled as a Qualified Residential Treatment Program (QRTP-provider type 68) at the same time.
Required Attachments:
  • Copy of the Licensed Psychologist or Physician who is affiliated with the group

  • Department of Human Services Permanent Child Care License indicating Service Type as Residential Child Care Facility.

  • Department of Human Services Office of Behavioral Health Attestation letter of a successful site review for providing mental health services (required for in-state providers only)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Rural Health Clinic
Specialty: Hospital Based
Specialty Code: 398
OR Specialty: Freestanding
Specialty Code: 472
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Copy of the license of the physician, osteopath, advanced practice nurse or physician assistant who is affiliated with the group.

  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed?Yes BT Allowed? Yes
School Health Services
Specialty: School Health Services
Specialty Code: 475
  • Each school district must complete a separate revalidation.
  • For the "Disclosures" section of the revalidation,school districts only need to disclose their superintendent and CFO rather than their elected board of officials. The superintendent and CFO information must be entered in the Managing employee section (Section D) of the disclosures page. Please indicate "CFO" or "Superintendent" following the listed individual's name.
Required Attachments:
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? No
Speech Therapist
Specialty: Speech Therapist
Specialty Code: 452
  • Complete only one revalidation for an individual regardless of number of affiliated groups.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Substance Use Disorder - Clinics
Specialty: Substance Use Disorder - Clinics
Specialty Code: 477
  • Each location must complete a separate revalidation.
  • Each location must verify and/or update the number of beds during revalidation.
Required Attachments:
  • Department of Human Services Office of Behavioral Health License
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes

 

Specialty: Special Connections
Specialty Code: 870
  • Each location must complete a separate revalidation.
  • Each location must verify and/or update the number of beds during revalidation.
Required Attachments:
  • Department of Human Services, Office of Behavioral Health License (specific to "Gender-Responsive Treatment)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes

 

Specialty Code: 871: Specialty: ASAM Level 3.1 CMLIRS (Clinically Managed Low-Intensity Residential Services)
Specialty Code: 872 Specialty: ASAM Level 3.3 CMPSHIRS (Clinically Managed Population-Specific High-Intensity Residential Services)
Specialty Code: 873 Specialty: ASAM Level 3.5 CMHIRS (Clinically Managed High-Intensity Residential Services)
Specialty Code: 874 Specialty: ASAM Level 3.7 MMIIS (Medically Monitored Intensive Inpatient Services)
Specialty Code: 875 Specialty: ASAM Level 3.2 WM CMRWM (Clinically Managed Residential Withdrawal Management)
Specialty Code: 876 Specialty: ASAM Level 3.7 WM MMIWM (Medically Monitored Inpatient Withdrawal Management)
 

ENROLLMENT TYPE: Facility

  • Each location must complete a separate revalidation.
  • Each location must verify and/or update the number of beds during revalidation.
Required Attachments:
  • Department of Human Services, Office of Behavioral Health License (specific to the ASAM level being enrolled)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Limited Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Substance Use Disorder - Individuals
THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR ENROLLMENTS. Services may be provided under the "Licensed Behavioral Health Clinician" Provider Type.
Supply
Specialty: Durable Medical Equipment (DME) (SSN Only)
Specialty Code: 480
  • Complete only one revalidation for an individual.
Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on file.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screenprint from the accreditation agency's website
  • Sales Tax License or Tax Exempt Certificate - (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location on file. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional

 

Specialty: Complex Rehabilitation Technology(CRT) (EIN Only)
Specialty Code: 481
  • Each service location must complete a separate revalidation and pay a separate fee.
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 file.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screenprint from the accreditation agency's website
  • Sales Tax License or Tax Exempt Certificate - (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location on file. If the address is not on the certificate, a screenprint of the Sales Tax Account indicating matching service location address is acceptable.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional

 

Specialty: Durable Medical Equipment (DME) (EIN Only)
Specialty Code: 482
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on file.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screenprint from the accreditation agency's website
  • Sales Tax License or Tax Exempt Certificate - (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location on file. If the address is not on the certificate, a screenprint of the Sales Tax Account indicating matching service location address is acceptable.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Conditional BT Allowed? Conditional

 

Specialty: Supply (without DME) (EIN Only)
Specialty Code: 483
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on file.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screenprint from the accreditation agency's website
  • Sales Tax License or Tax Exempt Certificate - (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.)  Address on document must match the service location on file. If the address is not on the certificate, a screenprint of the Sales Tax Account indicating matching service location address is acceptable.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes

 

Specialty: Supply (without DME) (SSN Only)
Specialty Code: 485
  • Complete only one revalidation for an individual.
Required Attachments:
  • CMS DMEPOS Accreditation
    • CMS DMEPOS Accreditation must be specific to the provider's location address on file.
    • Provider must submit one of the following CMS DMEPOS documents which contains the provider's name, address, city, state, and a current CMS DMEPOS accreditation date span:
      • CMS DMEPOS Accreditation certificate
      • Approval letter from the accreditation agency
      • Screenprint from the accreditation agency's website
  • Sales Tax License or Tax Exempt Certificate - (Wholesale Tax License not acceptable)(Out of State providers must submit a similar document from their own state indicating the enrolling entity is legally permitted to conduct business.) Address on document must match the service location on file. If the address is not on the certificate, a screenprint of the Sales Tax Account indicating matching service location address is acceptable.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes
Transportation
Specialty: Air - Emergent & Non-Emergent
Specialty Code: 086
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • License (attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes

 

Specialty: County Agency, Non Metro Area
Specialty Code: 124
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Ambulance License(attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd?No NPI Req'd? Yes
Medicare Req'd? No OOS Allowed? Yes BT Allowed? Yes

 

Specialty: Emergency
Specialty Code: 324
  • Each service location must complete a separate revalidation and pay a separate fee.
Required Attachments:
  • Ambulance license(attach a copy of current license and complete the license information in revalidation)
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes

 

Specialty: Non-Emergency Medical - Broker Network Participant
Specialty Code: 326
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Licensure as identified in 10 CCR 2505.10 8.014 must submit one of the following:
    • PUC license
    • Ground Ambulance License
    • PUC Medicaid Transportation Permit (MCT) To obtain a PUC (MCT) follow the directions outlined on the NEMT Provisional Agreement.
    • Official exemption decision document from the PUC
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No BT Allowed? No

 

Specialty: Non-Emergency Medical - Outside Broker Service Area
Specialty Code: 525
  • Each service location must complete a separate revalidation.
Required Attachments:
  • Licensure as identified in 10 CCR 2505.10 8.014 must submit one of the following:
    • PUC license
    • Ground Ambulance License
    • PUC Medicaid Transportation Permit (MCT) To obtain a PUC (MCT) follow the directions outlined on the NEMT Provisional Agreement.
    • Official exemption decision document from the PUC
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? No NPI Req'd? No
Medicare Req'd? No OOS Allowed? No BT Allowed? Yes
X-Ray Facility
Specialty: X-Ray Facility
Specialty Code: 495
  • Each service location must complete a separate revalidation and pay a separate application fee.
Required Attachments:
  • Department of Public Health and Environment RCD59-1 CE Report required for instate, service address must match the service location address on file. OOS must submit similar document or X-ray license from own state.
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.
Risk Level: Moderate Fee Req'd? Yes NPI Req'd? Yes
Medicare Req'd? Yes OOS Allowed? Yes BT Allowed? Yes