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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  

Addtional Documentation Need

 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-MR 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

 → PCP_Application
 → PCP_Contract

 Outpatient Substance Abuse
     ♦ Clinic (EIN)
     ♦ Individual (SSN)

Clinic 
Individual 

 

 Pharmacy

X
 

  → Out of State Letter
 → Dispensing Fee Attestation Form

 Physical Therapist (SSN)

 X

 

 Physician (SSN)

 X

  → PCP_Application
  → PCP_Contract

 Podiatrist (SSN)

 X

 

 Psychiatric Residential Treatment Facility

 X

 

 Psychologist (PhD or MA) (SSN)

 X

 → How to bill for mental 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