Rendering Application

Rendering Provider Application enrollment requires a SSN only. A rendering provider is the individual that provides services to a Medicaid client. In most instances, a rendering provider has the option to be either a direct pay entity or an indirect pay entity under only his/her SSN. If an individual has obtained an EIN to identify a business entity, both a rendering and a standard application may  need to be completed. For instance a dentist will need to enroll once as an indirect pay, or rendering provider, using his/her SSN and as a direct pay provider using the EIN to complete the Standard Provider Application for a dental clinic.

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

Rendering Provider Application  ♦ SSN only  ♦ Must affiliate to a billing/direct     pay entity Electronic Fillable Rendering Application	Additional Documentation
Audiologist
Certified Registered Nurse Anesthetist
Dental Hygienist
Dentist
Nurse-Midwife
Nurse Practitioner
Occupational Therapist
Optometrist
Orthodontist
Osteopath	→ PCP_Application → PCP_Contract
Physical Therapist
Physician	→ PCP_Application → PCP_Contract
Physician Assistant
Podiatrist
Psychologist (PhD or MA)	→ How to bill for mental health services
Registered Nurse	→ Supervision Form
Speech Therapist

 

 

Department of Health Care Policy and Financing · 1570 Grant Street · Denver, CO 80203-1818 · (303) 866-2993 Phone · (303) 866-4411 Fax