Provider Type Information for Revalidation

Revalidation Information by Provider Type

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.

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 Health ASO

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

• Contract with the Department of Human Services, Behavioral Health Administration.
• Each service location must complete a separate application.

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

Behavioral Health Crisis Line

Specialty: Behavioral Health Crisis Line
Specialty Code: 888

• Each service location must complete a separate revalidation.

Required Attachments:

• Proof of Colorado Crisis Services Crisis Line contract with the Colorado Department of Human Services (CDHS), Behavioral Health Administration (previously known as the Office of Behavioral Health).
  • 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 Req'd?	No	NPI Req'd?	No
Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

Behavioral Health Crisis Services

Specialty: Mobile Crisis Response
Specialty Code: 772

• Each service location must complete a separate revalidation.

Required Attachments:

• Colorado Department of Human Services Behavioral Health Administration (BHA) license for mobile crisis response services.
• Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician or osteopath who is affiliated to 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?	No	NPI Req'd?	Yes
Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

Behavioral Health MSO

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

• Contract with the Department of Human Services, Behavioral Health Administration.
• Each service location must complete a separate application.

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

Behavioral Health Secure Transportation

Specialty: Secure Transportation
Specialty Code: 773

• Each service location must complete a separate revalidation.

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.
• 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

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 Form, which can be found 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

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

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

• 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

Chiropractor-QMB

Specialty:Chiropractor-QMB
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

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
OR
Specialty: Telemedicine
Specialty Code: 878

• 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, Behavioral Health Administration (previously known as the 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

Dental Therapist

Specialty: Dental Therapist
Specialty Code: 776

• 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.)
• 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 HMO/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:

• Click here for Information by HCBS Service Provided

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?	No	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

Medicare Only Providers

Provider Type:90

Specialty: Histocompatibility Laboratory
Specialty Code: 890

• 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?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

 

Specialty: Home Infusion Therapy Supplier
Specialty Code: 891

• Each service location must complete a separate revalidation and pay a separate fee.

Required Attachments:

• Accreditation as a Home Infusion Therapy Supplier
• 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

 

Specialty: Independent Diagnostic Testing Facility
Specialty Code: 897

• Each service location must complete a separate revalidation and pay a separate fee.

Required Attachments:

• Copy of the License for the Supervising Physician
• 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: Mammography Screening Center
Specialty Code: 893

• Each service location must complete a separate revalidation and pay a separate fee.

Required Attachments:

• Food and Drug Administration (FDA) valid provisional certificate or valid certificate as a Mammography Screening 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?	Yes	NPI Req'd?	Yes
Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

 

Specialty: Medicare Diabetes Prevention Program Supplier
Specialty Code: 895

• Each service location must complete a separate revalidation.

Required Attachments:

• 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).
• 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?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

 

Specialty: Medicare Only Hospital
Specialty Code: 892

• 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?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

 

Specialty: Opioid Treatment Program
Specialty Code: 898 (High Risk with initial enrollment)
                         896 (Moderate Risk with initial enrollment)

• Each service location must complete a separate revalidation.

Required Attachments:

• Current SAMHSA certification for an Opioid Treatment Program.
• 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?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

 

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

• 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?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

Non-Physician Practitioner - Group

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

• 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, which can be found 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 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, Office of Early Childhood, Division of Early Care and Learning, Time Limited Child Care License indicating Service Type as: Residential Child Care Facility. (Required for in-state providers only.)
• Department of Human Services, Behavioral Health Administration (previously known as the 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

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, 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, which can be found on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, 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

Recovery Support Services Organization

Specialty: Peer Support Organization
Specialty Code: 889

Enrollment Type: Group

• Each service location must complete a separate revalidation.

Required Attachments:

• Department of Human Services, Behavioral Health Administration (previously known as the Office of Behavioral Health) 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.
• 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

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, 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)
• 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

 

Specialty: School Health Services
Specialty Code: 777

• Complete only one revalidation for an individual regardless of number of affiliated groups.
• This specialty (School Health Services) and the Speech Therapist (452) cannot be active at
  the same time.

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 Req'd?	No	NPI Req'd?	Yes
Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

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, Behavioral Health Administration (previously known as the 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, Behavioral Health Administration (previously known as the 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, Behavioral Health Administration (previously known as the 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?	No	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 (if applicable)
  • 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 (if applicable)
  • 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