Information by Provider Type

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Instructions for Step 1

Revalidation and enrollment requirements will vary based on your provider type, so it's important that you know what provider type(s) you are or want to enroll as.

Please review the available provider types supported in the Colorado interChange (our new claims payment system) on this web page; these are the ONLY provider types the Online Provider Enrollment tool will accept.

Note that if you are applying as more than one type of provider (Provider Type) your Enrollment Type may be different for each application (you need to submit a separate application for each type of provider you want to enroll as).

After you have found your provider type you may move on to step 2.

Frequently Asked Questions

I provide waiver services, what provider type is this?

You are likely referring to the Home and Community Based Services (HCBS) provider type.

Terms and Definitions

RISK LEVEL

Your provider type has been designated low, moderate, or high risk as required by Federal regulation; please see our Revalidation and Enrollment FAQs for more information.

FEE REQ’D?

Your provider type may be required to pay an application fee as required by Federal regulation. Please see our Revalidation and Enrollment FAQs for more information.

NPI REQ’D?

Your provider type may be required to have a National Provider Identifier (NPI).

MEDICARE REQ’D?

Your provider type may be required to enroll as a Medicare provider before enrolling as a Colorado Medicaid provider.

OOS ALLOWED?

(Out-of-state enrollment allowed?) Most of our providers are located in Colorado, but we do allow certain types of providers to enroll even if they are located out-of-state.

BT ALLOWED?

(Border town enrollment allowed?) Most of our providers are located in Colorado, but we do allow certain types of providers to enroll if they are located 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 enrollment details.

Ambulatory Surgery Center (ACS)

Provider Code: 44

Specialty: Ambulatory Surgery Center
Specialty Code: 300

Additional Requirements:

Each location must complete a separate application and pay a separate application fee

Required CERTIFICATIONS AND/OR LICENSES:

Facility’s license from the Colorado Department of Public Health and Environment
If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Audiologist

Provider Code: 19

Specialty: Audiologist
Specialty Code: 310

Additional Requirements:

Each location must complete a separate application and pay a separate application fee

Required CERTIFICATIONS AND/OR LICENSES:

For hearing aid dispensing and the Children’s Hearing Aid Program (CHAP):
- License from the Colorado Department of Regulatory Agencies (DORA)
For the Colorado Hearing Intervention Program (CHIP):
- License from the Colorado Department of Public Health and Environment

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

BHO

Provider Code: 31

ATTENTION! Do NOT enroll as this provider type unless you have a full risk, Capitated Managed Care Contract with the Department of Health Care Policy and Financing.

If you are trying to enroll as a Substance Use Disorder services provider, please see provider types “Substance Use Disorder – Clinics” or “Substance Use Disorder – Individuals”.
If you are trying to enroll as an individual Psychologist, please see provider types “Psychologist – Doctorate”, “Psychologist – Masters” or “Psychologist – Bachelors”.
If you are trying to enroll as a group that provides mental health counseling services, please see provider type “Non-Physician Practitioner Group”.
If you are trying to enroll as a provider of Home and Community-Based Services (waiver services), please see provider type “Home and Community Based Services (HCBS)”.

Specialty: BHO (Capitation)
Specialty Code: 431

Additional Requirements:

Attention: This Provider Type is no longer required to pay the application fee. When you get to the “Attachments and Fees” page of the application, please do not pay the application fee (you can just continue on to the next page of the application). If you have already paid the application fee as this Provider Type, please complete and submit this Application Fee Refund form to request a refund.Each location must complete a separate application and pay a separate application fee
All qualified rendering providers in BHO networks must enroll (separate application) and affiliate with the BHO
MCO/BHO Revalidation and Enrollment FAQs

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Billing Agent

Provider Code: 53

Specialty: Agency
Specialty Code: 320

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Individual
Specialty Code: 325

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Birthing Center

Provider Code: 58

Specialty: Free Standing Birthing Center
Specialty Code: 116

Additional Requirements:

Rendering providers must be enrolled (separate application) and must be Certified Nurse Midwives or Physicians
No Direct Entry Midwives (Non-DORA certified) are to be enrolled
Each service location must complete a separate application

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
License from the Colorado Department of Public Health and Environment (CDPHE)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Case Manager

Provider Code: 11

Specialty: Case Manager
Specialty Code: 330

Additional Requirements:

Each business location must complete a separate application
EFT Exemption Instructions (if you do not want to provide EFT information)

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Certified Addiction Counselor (CAC)

Special Instructions:

Please see the provider type "Substance Use Disorder – Individual (63)"
Per 10 CCR 2505-10 8.746 (appendix A) Health First Colorado (Colorado's Medicaid program) cannot enroll a CAC who doesn’t have Masters or Doctorate level education.

Certified Registered Nurse Anesthetist (CRNA)

Provider Code: 40

Specialty: Certified Registered Nurse Anesthetist (CRNA)
Specialty Code: 340

Required CERTIFICATIONS AND/OR LICENSES:

License from the Board of Nursing
Certification from National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Clinic - Dental

Provider Code: 47

Specialty: Clinic - Dental
Specialty Code: 350

Additional Requirements:

Dentists and dental hygienists must be enrolled individually (separate application) and associated with the dental clinic
Each service location must complete a separate application
Dental clinics must be owned by one of the following entities:
- a licensed dentist or dental hygienist
- a political subdivision - such as a county
- a non-profit corporation
- a non-licensed heir of a deceased licensed dentist per 12-35-116.5, C.R.S.

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
The owner’s license from the Board of Dental Examiners (if the owner is in-state and a licensed dentist or dental hygienist)
Certificate of Good Standing issued by the Colorado Secretary of State for a non-profit corporation (if non-profit)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Clinic - Practitioner

Provider Code: 16

Specialty: Clinic - Practitioner
Specialty Code: 351

Additional Requirements:

Must have at least one enrolled, licensed practitioner (MD, DO, OD, or DPM) affiliated with the clinic.
Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic
Each service location must complete a separate application

Required CERTIFICATIONS AND/OR LICENSES:

Copy of the individual license for the MD, DO, OD, or DPM who will affiliate to the clinic.
If lab work if performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Community Mental Health Center

Provider Code: 35

Specialty: Community Mental Health Center
Specialty Code: 360

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic
Each service location must complete a separate application

Required CERTIFICATIONS AND/OR LICENSES:

License/Certification from the Colorado Department of Public Health and Environment (CDPHE)
If lab work if performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Dental Hygienist

Provider Code: 66

Specialty: Dental Hygienist
Specialty Code: 066

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Board of Dental Examiners License
National Specialty Board Certification (if applicable)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Dentist

Provider Code: 04

Specialty: Oral Surgery
Specialty Code: 061

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within a Group – may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Board of Dental Examiners License
Certificate from the Board of Medical Examiners

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Dentist
Specialty Code: 062

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Board of Dental Examiners License

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Orthodontist
Specialty Code: 063

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Board of Dental Examiners License
National Specialty Board Certification (Orthodontist)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Dermatologist or Dermatology Clinic

SPECIAL INSTRUCTIONS:

Dermatologists should enroll as the 'physician' provider type, and then indicate dermatology, as a specialty, through their taxonomy code.
A dermatology clinic should enroll as the 'Clinic - Practitioner Group' provider type, and then indicate dermatology, as a specialty, through their taxonomy code.
- On the first page of the application, make sure you indicate a dermatology specialty using the taxonomy code.
- On the second page of the application, choose 'Clinic/Center' from the dropdown list; there isn't a dermatology option listed here.

Developmental Evaluation Clinic

Provider Code: 46

Specialty: Developmental Evaluation Clinic
Specialty Code: 370

Additional Requirements:

Each location must complete a separate application.
Medical Director must be enrolled (separate application), and associated with the clinic.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
License from the Colorado Department of Public Health and Environment .

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Dialysis Center

Provider Code: 33

Specialty: Dialysis Center
Specialty Code: 375

Additional Requirements:

Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
License from the Colorado Department of Public Health and Environment .

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Durable Medical Equipment (DME)

Special Instructions:

Please see 'Supply Facility', 'Supply Billing Individual', or 'Pharmacy (Pharmacy with DME)'

Family Planning Clinic

Provider Code: 29

Specialty: Family Planning Clinic
Specialty Code: 145

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application.

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Public Health and Environment .

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Federally Qualified Health Center

Provider Code: 32

Specialty: Freestanding
Specialty Code: 150

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. you do NOT need to complete a separate application for mental health or dental services since they are occurring at the same site location). However, you will need to complete a separate application for a pharmacy ID (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

HRSA "Notice of Award of a Section 330 Grant", or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

Specialty: Hospital Based
Specialty Code: 160

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. you do NOT need to complete a separate application for mental health or dental services since they are occurring at the same site location). However, you will need to complete a separate application for a pharmacy ID (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

HRSA "Notice of Award of a Section 330 Grant", or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

Specialty: Denver Health and Hospital School Based Clinics
Specialty Code: 199

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. you do NOT need to complete a separate application for mental health or dental services since they are occurring at the same site location). However, you will need to complete a separate application for a pharmacy ID (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

HRSA "Notice of Award of a Section 330 Grant", or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? No

Foreign Teaching Physician

Provider Code: 65

Specialty: Foreign Teaching Physician
Specialty Code: 500

Additional Requirements:

Individual within Group – may associate with multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Board of Medical Examiners – Distinguished Foreign Teaching Physician License
National Specialty Board Certification Required (if applicable)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Genetic Counselor

Provider Code: 76

Specialty: Genetic Counselor
Specialty Code: 760

Additional Requirements:

Billing Individual - must complete separate application for each service location
Individual within a Group - Must associate with a clinic or group during enrollment. If you are part of more than one group or clinic, you can associate to multiple groups/clinics in one application. Individual only needs to complete one enrollment application.

Required CERTIFICATIONS AND/OR LICENSES:

Genetic Counseling Master's Degree
American Board of Genetic Counseling Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Health Maintenance Organization (HMO)

Provider Code: 23

Specialty: Health Maintaince Orginization (HMO)
Specialty Code: 391

Additional Requirements:

Attention: This Provider Type is no longer required to pay the application fee. When you get to the “Attachments and Fees” page of the application, please do not pay the application fee (you can just continue on to the next page of the application). If you have already paid the application fee as this Provider Type, please complete and submit this Application Fee Refund form to request a refund.Each location must complete a separate application and pay a separate application fee
All qualified rendering providers in HMO networks must enroll (separate application) and affiliate with the HMO
MCO/BHO Revalidation and Enrollment FAQs

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Division of Insurance

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Home & Community Based Services (HCBS)

Provider Code: 36

Special Instructions:

Click here for Information by HCBS Service Provided (Step 1.5)

Home Health

Provider Code: 10

Specialty: Home Health
Specialty Code: 385

Additional Requirements:

Each service location must complete a separate application and pay a separate application fee.
Insurance Requirements

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Public Health and Environment (CDPHE)

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospice

Provider Code: 50

Specialty: Hospice
Specialty Code: 390

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospital - General

Provider Code: 01

Specialty: Hospital - General
Specialty Code: 301

Additional Requirements:

Each service location must complete a separate application and pay a separate application fee
Professional services must be submitted by the professional. Hospitals do not have individual associations

Required CERTIFICATIONS AND/OR LICENSES:

Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation that shows effective date and expiration date.
Medicare Approval/Certification Letter with the Medicare Outpatient Cost to Charge Rate (except Long Term Acute Care Hospitals and any out-of-state).
Proof of JCAHO accreditation (if applicable)
License from the Colorado Department of Public Health and Environment

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospital - Mental

Provider Code: 02

Specialty: Hospital - Mental
Specialty Code: 302

Additional Requirements:

Each service location must complete a separate application and pay a separate application fee.
Professional services must be submitted by the professional. Hospitals do not have individual associations.
A contract with the Department of Health Care Policy and Financing is required (in-state only).

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation.
Medicare Approval/Certification Letter with the Medicare Outpatient Cost to Charge Rate (except Long Term Acute Care Hospitals and any out-of-state).
Proof of JCAHO accreditation (if applicable)
License from the Colorado Department of Public Health and Environment .

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? No

Independent Laboratory

Provider Code: 12

Specialty: Independent Laboratory
Specialty Code: 410

Additional Requirements:

Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
Medicare Approval/Certification Letter with the Medicare Outpatient Cost to Charge Rate (except Long Term Acute Care Hospitals and any out-of-state)

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

Provider Code: 61

Specialty: Indian Health Services
Specialty Code: 170

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee. All services provided at that site will be captured within the site application (i.e. you do NOT need to complete a separate application for mental health or dental services since they are occurring at the same site location). However, you will need to complete a separate application for a pharmacy ID (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

HRSA "Notice of Award of a Section 330 Grant", or a copy of the Electronic Grant Handbook pages with the service location highlighted, if not enrolled in Medicare.
If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

Indian Health Services - Pharmacy

Provider Code: 62

Specialty: Indian Health Services
Specialty Code: 420

Additional Requirements:

Each pharmacy location must complete a separate application
Each pharmacy service location must have a unique National Provider Identifier (NPI)
Dispensing Fee Attestation Worksheet must be completed (part of the online application)
~~If Out-of-State, must complete the Out of State Pharmacy Questionnaire (part of the online application)~~ Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questioner will still appear in the application, however due to legislative changes it is no longer required to be completed.

Required CERTIFICATIONS AND/OR LICENSES:

National Council of Prescription Drug Programs (NCPDP) Certification (see instructions here)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Licensed Clinical Social Worker (LCSW)

Special Instructions:

There is not a provider type called "Licensed clinical social worker". LCSWs should use the provider type 'Psychologist “ Masters' or 'Psychologist “ Doctorate', respectivly. LCSW is indicated through the taxonomy code.
Proof of education Master's Degree and American College of Social Work (ACSW) or Clinical Social Worker (CSW) licensure is required

Licensed Marriage and Family Therapist (LMFT)

Special Instructions:

There is not a provider type called "Licensed Marrige and Family Therapist". LMFTs should use the provider type 'Psychologist “ Masters' or 'Psychologist “ Doctorate', respectivly. LMFT is indicated through the taxonomy code.

Licensed Professional Counselor (LPC)

Special Instructions:

There is not a provider type called "Licensed Professional Counselor". LPCs should use the provider type 'Psychologist “ Masters' or 'Psychologist “ Doctorate', respectivly. LPC is indicated through the taxonomy code.

Local Public Health Agencies (LPHA)

Special Instructions:

There is not a provider type called "Local Public Health Agency". LPHA's should use the provider type 'Clinic - practitioner'.
- The organization must be revalidated first. For the group application process to be completed, an Individual within a Group application must subsequently be submitted for the supervising MD/DO/NP. If your LPHA is led by an RN and is not affiliated with a qualified MD/DO/NP, the RN must check the “Certified Health Agency” box on his/her application (Individual Within a Group) to waive this requirement. You will also need to submit applications for any other providers who bill Medicaid.
If you are a county agency that reimburses for or provides non-emergency medical transportation (NEMT), you must also enroll or revalidate as:
- Enrollment Type: Atypical
- Provider Type: 73 - Transportation
- Specialty Code: Non-emergency medical (525)
If you are a county that is also an emergency ambulance provider, you must also enroll or revalidate as:
- Enrollment Type: Facility
- Provider Type: 13- Transportation
- Specialty Code Options:
  - County Agency, Non Metro Area (124)

Managed Care Organization (MCO)

Special Instructions:

Please see the provider type 'Health Maintenance Organization (HMO)'
Please also read these MCO/BHO Revalidation and Enrollment FAQs

Non-Physician Practitioner - Group

Provider Code: 25

Specialty: Non-Physician Practitioner - Group
Specialty Code: 441

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation

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

Provider Code: 24

Specialty: Non-Physician Practitioner - Individual
Specialty Code: 440

Additional Requirements:

Must associate with a clinic or group during enrollment. If you are part of more than one group or clinic, you can associate to multiple groups/clinics in one application.
RNs must complete and attach the ‘On premise supervision for non-physician practitioners’ form.

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA) for RNs
Behavior Analyst Certification Board (BACB) certificate for Board Certified Behavior Analysts

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Nurse Practitioner

Provider Code: 41

Specialty: Pediatric
Specialty Code: 034

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
License from the Board of Nursing
APN, CNS, NP, FNP, or PNP Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Family
Specialty Code: 035

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
License from the Board of Nursing
APN, CNS, NP, FNP, or PNP Certification.

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: General
Specialty Code: 335

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state.
License from the Board of Nursing
APN, CNS, NP, FNP, or PNP Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Nurse-Midwife

Provider Code: 22

Specialty: Nurse-Midwife
Specialty Code: 080

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
License from the Board of Nursing
American college of Nurse-Midwifes certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Nursing Facility

Provider Code: 20

Specialty: Nursing Facility - Hospital Back Up Program
Specialty Code: 382

Additional Requirements:

Each Nursing Facility location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
License from the Colorado Department of Public Health and Environment

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Nursing Facility - Regular
Specialty Code: 392

ADDITIONAL REQUIREMENTS:

Each Nursing Facility location must complete a separate application and pay a separate application fee.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation.
License from the Colorado Department of Public Health and Environment.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Nursing Facility - Swing Beds
Specialty Code: 396

Additional Requirements:

Each Nursing Facility location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation.
License from the Colorado Department of Public Health and Environment.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Nursing Facility - ICF/IID

Provider Code: 21

Specialty: ICF/IID - Private
Specialty Code: 383

Additional Requirements:

Each Nursing Facility location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation.
License from the Colorado Department of Public Health and Environment.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: ICF/IID - State
Specialty Code: 394

ADDITIONAL REQUIREMENTS:

Each Nursing Facility location must complete a separate application and pay a separate application fee.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
License from the Colorado Department of Public Health and Environment.

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Occupational Therapist

Provider Code: 28

Specialty: Occupational Therapist
Specialty Code: 450

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Optician

Provider Code: 08

Specialty: Optician
Specialty Code: 395

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

If lab work is performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Optometrist

Provider Code: 07

Specialty: Optometrist
Specialty Code: 183

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA)
Board of Optometry Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Osteopath

Provider Code: 26

Specialty: Osteopath
Specialty Code: 501

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
If lab work if performed - Clinical Laboratory Improvement Amendments (CLIA) certificate of accreditation
National Specialty Board Certification (Optional)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Personal Care Agency

Provider Code: 60

Specialty: Personal Care Agency
Specialty Code: 560

Additional Requirements:

This provider type is only for pediatric personal care benefit members. Please visit the Personal Care benefit page more more information.
Each business location will need to enroll separately (separate application) and pay a separate fee.
The closest NPI taxonomy code is:
- Nursing & Custodial Care Facilities - Custodial Care Facility - 311Z00000X

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Public Health and Environment

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Pharmacy

Provider Code: 09

ATTENTION ALL PHARMACIES! In order to bill any type of Durable Medical Equipment and Supplies (DME) to Medicaid, you must also select the specialty type “Pharmacy with DME” on your provider application. That specialty type is required even if your pharmacy qualifies for the Medicare exemption from DME accreditation. If you select any other pharmacy specialty, your pharmacy will not be able to bill any DME to Medicaid effective October 31, 2016. Please be advised that “Pharmacy with DME” is a high risk level specialty which is subject to additional screening requirements.

Specialty: Mail Order
Specialty Code: 460

Additional Requirements:

Each pharmacy location must complete a separate application.
Each pharmacy service location must have a unique National Provider Identifier (NPI).
Dispensing Fee Attestation Worksheet must be completed (part of the online application).
~~If Out-of-State, must complete the Out of State Pharmacy Questionnaire (part of the online application)~~ Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questioner will still appear in the application, however due to legislative changes it is no longer required to be completed.

Required CERTIFICATIONS AND/OR LICENSES:

Colorado Board of Pharmacy license
National Council of Prescription Drug Programs (NCPDP) Certification (see instructions here)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Pharmacy
Specialty Code: 461

ADDITIONAL REQUIREMENTS:

Each pharmacy location must complete a separate application
Each pharmacy service location must have a unique National Provider Identifier (NPI)
Dispensing Fee Attestation Worksheet must be completed (part of the online application)
~~If Out-of-State, must complete the Out of State Pharmacy Questionnaire (part of the online application)~~ Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questioner will still appear in the application, however due to legislative changes it is no longer required to be completed.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Colorado Board of Pharmacy license
National Council of Prescription Drug Programs (NCPDP) Certification (see instructions here)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Pharmacy with DME
Specialty Code: 462

ADDITIONAL REQUIREMENTS:

Each pharmacy location must complete a separate application.
Each pharmacy service location must have a unique National Provider Identifier (NPI).
Dispensing Fee Attestation Worksheet must be completed (part of the online application).
~~If Out-of-State, must complete the Out of State Pharmacy Questionnaire (part of the online application)~~ Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questioner will still appear in the application, however due to legislative changes it is no longer required to be completed.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Colorado Board of Pharmacy license
National Council of Prescription Drug Programs (NCPDP) Certification (see instructions here)

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Rural Dispensing Physician Site
Specialty Code: 463

ADDITIONAL REQUIREMENTS:

Each pharmacy location must complete a separate application
Each pharmacy service location must have a unique National Provider Identifier (NPI)
Dispensing Fee Attestation Worksheet must be completed (part of the online application)
~~If Out-of-State, must complete the Out of State Pharmacy Questionnaire (part of the online application)~~ Note: OOS Pharmacy Questionnaire is no longer required. The OOS Questioner will still appear in the application, however due to legislative changes it is no longer required to be completed.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Colorado Board of Pharmacy license
National Council of Prescription Drug Programs (NCPDP) Certification (see instructions here)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Physical Therapist

Provider Code: 17

Specialty: Physical Therapist
Specialty Code: 451

Additional Requirements:

Billing Individual – must complete separate application for each service location
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Physician

Provider Code: 05

Specialty: Physician
Specialty Code: 505

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Certificate from the Board of Medical Examiners
National Specialty Board Certification (if applicable)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Physician Assistant

Provider Code: 39

Specialty: Physician Assistant
Specialty Code: 510

Additional Requirements:

Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Certificate from the Board of Medical Examiners

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Podiatrist

Provider Code: 06

Specialty: Podiatrist
Specialty Code: 194

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Podiatry Board Certification

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

Provider Code: 30

Specialty: Psychiatric Residential Treatment Facility
Specialty Code: 476

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

Department of Human Services License
License from the Colorado Department of Public Health and Environment

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Psychologist - Bachelors

Special Instructions:

Per 10 CCR 2505-10, Colorado Medicaid cannot enroll a Psychologist who doesn't meet Masters or Doctorate level education requirements

Psychologist - Doctorate

Provider Code: 37

Specialty: Psychologist - Doctorate
Specialty Code: 520

Additional Requirements:

Education Requirement - PhD, PsyD, or EdD.
Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency, if out-of-state.
Board of Psychology Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Psychologist - Masters

Provider Code: 38

Specialty: Psychologist - Masters
Specialty Code: 521

Additional Requirements:

Education Requirement - Master's Degree.
Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable)

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
- Must be licensed as a LCSW, LPC, or LMFT
Board of Psychology Certification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

QMB Benefits Only

Provider Code: 18

Specialty: QMB Benefits Only
Specialty Code: 321

Additional Requirements:

Proof of Lawful Pressence

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state
Chiropractic Board Certifiaction

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Regional Care Collaborative Organization (RCCO)

Provider Code: 57

Specialty: Regional Care Collaborative Organization
Specialty Code: 550

Additional Requirements:

PCMP (Primary Care Medical Provider) staff (MD/DO, NP, PA, etc.) must enroll separately in Medicaid. (Must complete a separate application and affiliate to the RCCO).
Attention: This Provider Type is no longer required to pay the application fee. When you get to the “Attachments and Fees” page of the application, please do not pay the application fee (you can just continue on to the next page of the application). If you have already paid the application fee as this Provider Type, please complete and submit this Application Fee Refund form to request a refund.

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Registered Nurse

Special Instructions:

See Non-Physician Practitioner

Rehabilitation Agency

Provider Code: 48

Specialty: Practitioner
Specialty Code: 397

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application.
Must have at least one enrolled physical, occupational, or speech therapist affiliated with the group.

Required CERTIFICATIONS AND/OR LICENSES:

Copy of the individual license for the physical, occupational, or speech therapist who will affiliate to the group.

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Comprehensive Outpatient Rehabilitation Facility
Specialty Code: 470

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Residential Child Care Facility

Provider Code: 52

Specialty: Mental Health Program
Specialty Code: 471

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

Department of Human Services License

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Rural Health Clinic

Provider Code: 45

Specialty: Hospital Based
Specialty Code: 398

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

Specialty: Freestanding
Specialty Code: 472

Additional Requirements:

Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and associated with the clinic.
Each service location must complete a separate application and pay a separate application fee.

Required CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

School Health Services

Provider Code: 51

Specialty: School Health Services
Specialty Code: 475

Additional Requirements:

Individual School Health Services providers do not have to be enrolled.
Each school district must complete a separate application.
For the "Disclosures" section of the application, 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 CERTIFICATIONS AND/OR LICENSES:

None

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Speech Therapist

Provider Code: 27

Specialty: Speech Therapist
Specialty Code: 452

Additional Requirements:

Billing Individual – must complete separate application for each service location.
Individual within Group – must associate to at least one group; may associate to multiple groups on one application (if applicable).

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA), or appropriate state agency if out-of-state.

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

Provider Code: 64

Specialty: Substance Use Disorder - Clinics
Specialty Code: 477

Additional Requirements:

Each location must complete a separate application.
SUD Clinic Supervisor Attestation Form
SUD Clinics may only enroll if they are Supervised by:
- Licensed physicians who are also:
  - Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN); or
  - Certified as National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or
  - Certified as Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
  - Certified in addiction medicine by the American Society of Addiction Medicine (ASAM); or
- Licensed non-physician who are:
  - Psychologists (PhD, PsyD)
  - Nurse Practitioners, or
  - Master’s Level Clinicians (provider type 38) and:
    - Licensed Clinical Social Worker (LCSW)
    - Licensed Professional Counselor (LPC)
    - Licensed Marriage and Family Therapist (LMFT)
  - AND one or both of the following:
    - Certified by DORA as a CAC II, CAC III or Licensed Addiction Counselors (LAC)
    - Certified by NAADAC as an NCAC II or MAC

Required CERTIFICATIONS AND/OR LICENSES:

Approval by the Department of Human Services or the DHS Office of Behavioral Health

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Substance Use Disorder - Individuals

Provider Code: 63

Specialty: Substance Use Disorder - Individuals
Specialty Code: 399

Additional Requirements:

SUD individuals may only enroll if they are:
- Licensed physicians who are also:
  - Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN); or
  - Certified as National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or
  - Certified as Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
  - Certified in addiction medicine by the American Society of Addiction Medicine (ASAM); or
- Licensed non-physician who are:
  - Psychologists (PhD, PsyD)
  - Nurse Practitioners, or
  - Master’s Level Clinicians (provider type 38) and:
    - Licensed Clinical Social Worker (LCSW)
    - Licensed Professional Counselor (LPC)
    - Licensed Marriage and Family Therapist (LMFT)
  - AND one or both of the following:
    - Certified by DORA as a CAC II, CAC III or Licensed Addiction Counselors (LAC)
    - Certified by NAADAC as an NCAC II or MAC

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Regulatory Agencies (DORA).

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Supply

Provider Code: 74

Specialty: Durable Medical Equipment (DME) (SSN Only)
Specialty Code: 480

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

CMS DMEPOS Accreditation
- CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
- 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
  - Screen print from the accreditation agency's website
Business license (sales tax certificate) or tax exempt certificate

Risk Level: High

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Supply - WITHOUT DURABLE MEDICAL EQUIPMENT (DME) (SSN ONLY)
Specialty Code: 485

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

CMS DMEPOS Accreditation
- CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
- 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
  - Screen print from the accreditation agency's website
Business license (sales tax certificate) or tax exempt certificate

Risk Level: High

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Provider Code: 14

Specialty: Complex Rehabilitation Technology (CRT) (EIN Only)
Specialty Code: 481

Additional Requirements:

None.

Required CERTIFICATIONS AND/OR LICENSES:

Medicare Approval/Certification Letter (if applicable)
CMS DMEPOS Accreditation
- CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
- 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
  - Screen print from the accreditation agency's website
Business license (sales tax certificate) or tax exempt certificate

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Durable Medical Equipment (DME) (EIN Only)
Specialty Code: 482

Additional Requirements:

None.

Required CERTIFICATIONS AND/OR LICENSES:

CMS DMEPOS Accreditation
- CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
- 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
  - Screen print from the accreditation agency's website
Business license (sales tax certificate) or tax exempt certificate

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Specialty: Supply - without Durable Medical Equipment (DME) (EIN ONLY)
Specialty Code: 483

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

CMS DMEPOS Accreditation
- CMS DMEPOS Accreditation must be specific to the provider's location address on the application.
- 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
  - Screen print from the accreditation agency's website
Business license (sales tax certificate) or tax exempt certificate

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Transportation

Provider Code: 13 - Emergency Medical Transportation and Air Ambulance

Specialty: Air - Emergent & Non-Emergent
Specialty Code: 086

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

Proof of Commission on Accreditation of Medical Transport Systems (CAMTS) Accreditation

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

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

None

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

Additional Requirements:

None

Required CERTIFICATIONS AND/OR LICENSES:

Ambulance license

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Provider Code: 73 - Non-Emergent Medical Transportation

Specialty: Transportation Broker - Non-Emergency Medical
Specialty Code: 326

Additional Requirements:

This is for non-emergency medical transportation (NEMT) providers, that are a part of Veyo’s network. If you are a NEMT provider in any of the following counties, you must be enrolled with Veyo: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, Weld.

Required CERTIFICATIONS AND/OR LICENSES:

PUC license, if applicable. To obtain a Medicaid Transportation Permit (MCT) follow the directions outlined here.

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
Specialty Code: 525

Additional Requirements:

This is for non-emergency medical transportation (NEMT) providers, including county departments of human services, that provide services in any county outside of: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, Weld.

Required CERTIFICATIONS AND/OR LICENSES:

PUC license, if applicable. To obtain a Medicaid Transportation Permit (MCT) follow the directions outlined here.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

X-Ray Facility

Provider Code: 49

Specialty: X-Ray Facility
Specialty Code: 495

Additional Requirements:

Each business location must complete a separate application, and pay a separate application fee.
If your business performs MRI procedures only, enroll as provider type 16 – Clinic – Practitioner.

Required CERTIFICATIONS AND/OR LICENSES:

License from the Colorado Department of Public Health and Environment

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

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