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Standard App

Standard Application

Standard Provider Application enrollment most often requires the use of a federal Employer Identification Number (EIN). This is a direct pay, or billing entity, where earnings/reimbursements are reported to the IRS under the EIN, with a few exceptions. Enrollment using an EIN usually requires at least one association, or affiliation, with the rendering individual/provider that will directly see/evaluate the Medicaid client. The direct pay entity usually/generally submits claims on behalf of the rendering individual.

Please find the applicable provider type and access all documentation needed in the following table: 

Standard Provider Application

     ♦ EIN only (except as indicated below)
     ♦ Billing/direct pay entity with IRS reporting

Checklist

Additional Documentation

 Ambulatory Surgical Center

X

 

 Audiologist (SSN)

X

 

 Behavioral Health Organization

X

 

 Case Manager

X

 

 Certified Registered Nurse Anesthetist (SSN)

X

 

 Chiropractor (SSN)

X

 

 Community Mental Health Clinic

X

 

 Dental Clinic

X

 

 Dental Hygienist (SSN)

X

 

 Dentist (SSN)

X

 

 Developmental Evaluation Clinic

X

 

 Dialysis Center

X

 

 Family Planning Clinic

X

 

 Federally Qualified Health Center (FQHC)

X

Prenatal Plus Program Participation Form  

HCBS Developmental Disabilities   (EIN or SSN depending on service)

X

 

HCBS BI/EBD/CMHS/PLWA/ CHCBS/CLLI/CWA Services (EIN or SSN depending on service)

X

 

 Health Maintenance Organization (HMO)

X

 

 Home Health

X

 → Home Health Letter 
 →
Insurance Requirements

 Hospice

X

 

 Hospital (General or Mental)

X

 → Enrollment for New Hospitals

 Independent Laboratory

X

 

 Non-Physician Practitioner Group

X

 

 Nursing Facility

X

 → ICF/IID Enrollment Process

 Nurse-Midwife (SSN)

X

 

 Nurse Practitioner (SSN)

X

 

 Occupational Therapist (SSN)

X

 

 Optician/Optical Outlet

X

 

 Optometrist (SSN)

X

 

 Organized Health Clinic

X

 → Prenatal Plus Program Participation Form

 Orthodontist (SSN)

X

 

 Osteopath (SSN)

X

 

 Outpatient Substance Use Disorder
     ♦ Clinic (EIN)
     ♦ Individual (SSN)

Clinic 
Individual

Important enrollment information for behavioral health services

 Pharmacy

X

 → Out of State Letter
 →
Dispensing Fee Attestation Form

 Physical Therapist (SSN)

X

 

 Physician (SSN)

X

 

 Podiatrist (SSN)

X

 

 Psychiatric Residential Treatment Facility

X

 

 Psychologist (MA) (SSN)
 Psychologist (PhD) (SSN)

Masters
PhD

 → Important enrollment information for behavioral health services

 Regional Care Coordination Organization (RCCO)

X

 → RCCO Contact Information
 →
RCCO Map

 Rehabilitation Agency (CORF or Practitioner)

X

 

 Residential Child Care Facility

X

 

 Rural Health Center

X

Prenatal Plus Program Participation Form  

 School Health Services

X

 

 Speech Therapist (SSN)

X

 

 Supply Business
     ♦ Business (EIN)
     ♦ Individual (SSN)

Business 
Individual

 → Out of State Letter

 Transportation (EIN or SSN for non-emergent, EIN for all others)

X

 

 X-Ray Facility

X