Information by Provider Type

Instructions for Step 1

Enrollment requirements will vary based on the provider type, so it's important to know what provider type(s) to enroll as.

Please review the provider types available in the Colorado interChange on this web page.

Note that if applying as more than one GROUP OR FACILITY Enrollment Type, a separate application for each is required.

Note that an individual enrolling via SSN is restricted to one enrollment.

Note that if waiver services are provided, select the Home and Community Based Services (HCBS) provider type.

Once the provider type is determined, proceed to step 2.

Terms and Definitions

RISK LEVEL

Each provider type has been designated low, moderate, or high risk.

FEE REQ’D?

The provider type may be required to pay an application fee as required by Federal regulation.

NPI REQ’D?

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

MEDICARE REQ’D?

The provider type may be required to enroll as a Medicare provider before enrolling as a Health First Colorado provider.

OOS ALLOWED?

(Out-of-state (OOS) enrollment allowed?) The provider type allows for out-of-state service locations to enroll.

BT ALLOWED?

(Border town (BT) enrollment allowed?) the provider type allows enrollment when the service location is 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.

Administrative Services Organization (ASO)

Provider TYPE 81

Specialty: Transportation
Specialty Code: 810
OR
Specialty: Dental
Specialty Code: 811

ENROLLMENT TYPE: Atypical

Contract with the Department
Each service location must complete a separate application
Credentialed professionals (rendering providers) must be enrolled individually (separate application)
- Transportation-810 ASO must have enrolled and affiliated providers
- Dental-811 ASO does not require affiliations, however, providers must also enroll separately with the Dental ASO

Required Attachments:

Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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)

Provider TYpe: 44

Specialty: Ambulatory Surgery Center
Specialty Code: 300

ENROLLMENT TYPE: Facility

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

Required Attachments:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Audiologist

Provider Type: 19

Specialty: Audiologist
Specialty Code: 310

ENROLLMENT TYPE: Billing Individual – directly bills for themselves

Individual within a Group – affiliates to a group and the group bills

Ordering, Referring, Prescribing – limited to Ordering/Referring/Prescribing

Complete only one enrollment application regardless of enrollment type and number of service locations

REQUIRED ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Behavioral Therapy - Clinic

Provider Type: 83

Specialty: Behavioral Therapy Clinic
Specialty Code: 830

ENROLLMENT TYPE: Group

Each service location must complete a separate application
Credentialed professionals (the rendering providers) must be enrolled individually (separate application), and affiliated with the clinic. Affiliations are restricted to Provider Type 84, Specialty 831-Behavioral Therapist, Provider Type 37, Specialty 520-Licensed Psychologist, Provider Type 38, Specialty 521 Licensed Behavioral Health Clinician.
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners

Required ATTACHMENTS:

Proof of Malpractice/Liability insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Copy of the individual's license or Board Certified Analyst certification, who will affiliate with the clinic

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Behavioral Therapy - Individual

Provider Type: 84

Specialty: Behavioral Therapist
Specialty Code: 831

ENROLLMENT TYPE: Billing Individual – directly bills for themselves OR

Individual within a Group – affiliates to a group and the group bills

Complete only one enrollment application regardless of enrollment type and number of service locations.
Individual within a Group enrollments may only affiliate with a Behavioral Therapy Clinic, and/or Non-Physician Practitioner Group.

Required Attachments:

Behavioral Therapy Provider Attestation Form must be completed
- Evidence of license, credential, training and/or experience must be included
Proof of Malpractice/Liability insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

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 NEW 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

PROVIDER TYPE: 58

Specialty: Free Standing Birthing Center
Specialty Code: 116

ENROLLMENT TYPE: Group

Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the group. Rendering providers must be Certified Nurse Midwives or Physicians
No Direct Entry Midwives (non-DORA certified) are to be enrolled
For new enrollments, the group must be approved prior to enrollment of the individual practitioners
Each service location must complete a separate application

Required Attachments:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Copy of the individual license for the Certified Nurse Midwife (CNM) or Physician who will affiliate to the Birthing Center

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Case Management Agency

PROVIDER TYPE: 11

Specialty: Contracted Case Management
Specialty Code: 330

ENROLLMENT TYPE: Atypical

Contract with the Department
Each service location must complete a separate application
EFT Exemption Instructions (to bypass the Electronic Funds Transfer (EFT) requirement)

Required ATTACHMENTS:

Proof of Malpractice/Liability insurance

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:

Per 10 CCR 2505-10 8.746 Health First Colorado (Colorado's Medicaid program) cannot enroll a CAC who isn’t also a licensed health professional (advanced practice nurse, physician/psychiatrist, physician assistant.)

Certified Registered Nurse Anesthetist (CRNA)

PROVIDER TYPE: 40

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

ENROLLMENT TYPE: Billing Individual – directly bills for themselves

      Individual within a Group – affiliates to a group and the group bills
      OR
      Ordering, Referring, Prescribing – limited to Ordering/Referring/Prescribing

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Clinic - Dental

PROVIDER TYPE: 47

Specialty: Clinic - Dental
Specialty Code: 350

ENROLLMENT TYPE: Group

Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
For new enrollments, the clinic must be approved prior to enrollment of the individual dentists and dental hygienists
Dental clinics must be owned by one of the following entities per 12-220-114, C.R.S. (formerly 12-35-116.5):
- 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
Each service location must complete a separate application

Required ATTACHMENTS:

License of the dentist or dental hygienist who owns the clinic
Certificate of Good Standing issued by the Colorado Secretary of State for a non-profit corporation ONLY
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Clinic - Practitioner

PROVIDER TYPE: 16

Specialty: Clinic - Practitioner
Specialty Code: 351

ENROLLMENT TYPE: Group

Must have at least one enrolled, licensed practitioner (MD, DO, OD or DPM) affiliated with the clinic
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
Each service location must complete a separate application

Required ATTACHMENTS:

Copy of the individual license for the MD, DO, OD or DPM who will affiliate to the clinic
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Community Clinic

PROVIDER TYPE: 86

Specialty: Community Clinic or Community Clinic & Emergency Center
Specialty Code: 860

ENROLLMENT TYPE: Facility

Each service location must complete a separate application.
Professional services must be submitted by the professional. Community Clinics do not have individual associations.

Required ATTACHMENTS:

Clinical Laboratory Improvement Amendments (CLIA) certificate
Medicare approval as a Community Clinic or Community Clinic & Emergency Center at the same service location address
Proof of JCAHO accreditation (optional)
License as a Community Clinic or Community Clinic & Emergency Center
Affiliation Addendum to the Hospital license showing the service location address is affiliated to a certain hospital
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

PROVIDER TYPE: 35

Specialty: Community Mental Health Center
Specialty Code: 360

ENROLLMENT TYPE: Group

Must have at least one enrolled, licensed practitioner affiliated with the clinic
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
Each service location must complete a separate application

Required ATTACHMENTS:

License
Copy of the individual license who will affiliate to the clinic
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Dental Hygienist

PROVIDER TYPE: 66

Specialty: Dental Hygienist
Specialty Code: 066

ENROLLMENT TYPE: Billing Individual – directly bills for themselves OR
Individual within a Group – affiliates to a group and the group bills

Complete only one enrollment application regardless of enrollment type and number of service locations.

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing iNdividual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Dentist

PROVIDER TYPE: 04

Specialty: Oral Surgery
Specialty Code: 061
OR

Specialty: Dentist
Specialty Code: 062
OR

Specialty: Orthodontist
Specialty Code: 063

ENROLLMENT TYPE: Billing Individual - directly bills for themselves
   OR
   Individual within a Group - affiliates to a group and the group bills
   OR
   Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License –Two separate licenses required - Dental and Physician for Oral Surgery specialty ONLY
- 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
National Specialty Board Certification for Orthodontist specialty ONLY
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

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 indicate dermatology as a specialty through the taxonomy code.
A dermatology clinic should enroll as the 'Clinic - Practitioner' provider type and indicate dermatology as a specialty through the taxonomy code.
- On the first page of the application, make sure to 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 TYPE: 46

Specialty: Developmental Evaluation Clinic
Specialty Code: 370

ENROLLMENT TYPE: Group

Each location must complete a separate application.
Medical Director must be enrolled (separate application), and associated with the clinic.
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners

Required ATTACHMENTS:

License from the Colorado Department of Public Health and Environment
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Dialysis Center

PROVIDER TYPE: 33

Specialty: Dialysis Center
Specialty Code: 375

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? Yes

Durable Medical Equipment (DME)

Special Instructions:

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

Family Planning Clinic

THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW 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

PROVIDER TYPE: 32

Specialty: Freestanding
Specialty Code: 150
OR

Specialty: Hospital Based
Specialty Code: 160
OR

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

ENROLLMENT TYPE: Group

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).
Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.

Required ATTACHMENTS:

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, OR receives HRSA designation as a look-alike entity, OR self-identifies as receiving funds under Title V of the Indian Health Care Improvement Act.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes (Only for Specialties 150 and 160)

Foreign Teaching Physician

PROVIDER TYPE: 65

Specialty: Foreign Teaching Physician
Specialty Code: 500

ENROLLMENT TYPE: Individual within a Group – affiliates to a group and the group bills

Complete only one enrollment application regardless of number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance

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)

PROVIDER TYPE: 23

Specialty: Health Maintenance Organization (HMO)
Specialty Code: 391
OR

Specialty: Health Maintenance Organization (HMO)/PACE
Specialty Code: 393

ENROLLMENT TYPE: Atypical

Contract with the Department
Each service location must complete a separate application
Credentialed professionals (rendering, ordering, prescribing and referring providers) in HMO networks must be enrolled individually (separate application)
MCO/RAE Enrollment FAQs

Required ATTACHMENTS:

License from the Colorado Division of Insurance - HMO Specialty 391 ONLY
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes-HMO/PACE-393, No-HMO-391

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Home & Community Based Services (HCBS)

PROVIDER TYPE: 36

Special Instructions:

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

Home Health

PROVIDER TYPE: 10

Specialty: Home Health
Specialty Code: 385

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospice

PROVIDER TYPE: 50

Specialty: Hospice
Specialty Code: 390

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License (License must include the service location address)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospital - General

PROVIDER TYPE: 01

Specialty: Hospital - General
Specialty Code: 301

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License (License must include an address that matches the service location address on the provider application)
- 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.
Clinical Laboratory Improvement Amendments (CLIA) certificate
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Hospital - Mental

PROVIDER TYPE: 02

Specialty: Hospital - Mental
Specialty Code: 302

ENROLLMENT TYPE: Facility

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 ATTACHMENTS:

License (License must include an address that matches the service location address on the provider application)
Clinical Laboratory Improvement Amendments (CLIA) certificate
Proof of JCAHO accreditation (optional)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? No

BT Allowed? No

Independent Laboratory

PROVIDER TYPE: 12

Specialty: Independent Laboratory
Specialty Code: 410

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

Clinical Laboratory Improvement Amendments (CLIA) certificate
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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 TYPE: 61

Specialty: Indian Health Services
Specialty Code: 170

ENROLLMENT TYPE: Group

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. a separate application is NOT required for mental health or dental services since they are occurring at the same site location). A separate application is required for a pharmacy (if applicable).
Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.

Required ATTACHMENTS:

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, OR receives HRSA designation as a look-alike entity, OR self-identifies as an IHS facility under the U.S. Department of Health and Human Services OR receives funds under Title V of the Indian Health Care Improvement Act.
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

PROVIDER TYPE: 62

Specialty: Indian Health Services
Specialty Code: 420

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Licensed Addiction Counselor (LAC)

Special Instructions:

There is not a provider type called "Licensed Addiction Counselor". LACs should use the provider type “Licensed Behavioral Health Clinician” or “Licensed Psychologist”, respectively. (“Licensed Psychologist” requires a PhD, PsyD or EdD in addition to the LAC.) LAC is indicated through the taxonomy code.

Licensed Behavioral Health Clinician

PROVIDER TYPE: 38

Specialty: Licensed Behavioral Health Clinician
Specialty Code: 521

ENROLLMENT TYPE: Billing Individual – directly bills for themselves
OR
Individual within a Group – affiliates to a group and the group bills

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License (LAC, LCSW, LPC, or LMFT)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

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 "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LCSW.) LCSW is indicated through the taxonomy code.

Licensed Marriage and Family Therapist (LMFT)

Special Instructions:

There is not a provider type called "Licensed Marriage and Family Therapist". LMFTs should use the provider type "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LMFT.) 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 "Licensed Behavioral Health Clinician" or "Licensed Psychologist", respectively. ("Licensed Psychologist" requires a PhD, PsyD or EdD in addition to the LPC.) LPC is indicated through the taxonomy code.

Licensed Psychologist

PROVIDER TYPE: 37

Specialty: Licensed Psychologist (PhD, PsyD, EdD)
Specialty Code: 520

ENROLLMENT TYPE: Billing Individual - directly bills for themselves
   Individual within a Group - affiliates to a group and the group bills
   OR
   Ordering, Referring, Prescribing - limited to Ordering/Referring/Prescribing

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Local Public Health Agencies (LPHA)

Special Instructions:

There is not a provider type called “Local Public Health Agency”. LPHAs should use the provider type “Clinic-Practitioner” or “Non-Physician Practitioner-Group” and the ‘Group’ enrollment type. Please review the specific requirements for these Provider Types to verify which is applicable.
For the application process to be completed, a minimum of three applications are required:
1. one for the organization (either a Clinic-Practitioner or a Non-Physician Practitioner-Group)
2. one for an individual enrollment for the supervising MD/DO (Clinic-Practitioner) or NP (Non-Physician Practitioner-Group)
3. one for an individual enrollment for the RN
  NOTE: An RN is required to be supervised by a qualified MD/DO/NP and the RN must complete the RN supervision area in the application.
- The organization must be enrolled first, before the individual(s) that work at the clinic.
- Additional applications must be submitted for each of the individuals that are affiliating with the clinic.
If you are a county agency that reimburses for or provides non-emergency medical transportation (NEMT), you must also enroll 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 as:
- Enrollment Type: Facility
- Provider Type: 13- Transportation
- Specialty Code: County Agency, Non Metro Area (124)

Managed Care Organization (MCO)

Special Instructions:

Please see the provider type 'Health Maintenance Organization (HMO)'

Non-Physician Practitioner - Group

PROVIDER TYPE: 25

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

ENROLLMENT TYPE: Group

Must have at least one licensed Behavioral Health Clinician, Psychologist, Nurse Practitioner, Nurse Midwife, Certified Registered Nurse Anesthetist, Physical Therapist, Occupational Therapist, Speech Therapist, Audiologist, or Behavioral Therapist affiliated with the clinic. NOTE: Behavioral Therapists must submit either BCBA certification or Behavioral Therapy Attestation Form.
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners.
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 ATTACHMENTS:

Copy of the individual license/certification/attestation form for the individual provider mentioned above who will affiliate to the Group
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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 TYPE: 24

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

ENROLLMENT TYPE: Individual within a Group – affiliates to a group and the group bills

This provider type is for Registered Nurses (RNs) only.
NOTE: Certified Registered Nurse Anesthetists, Nurse Practitioners and Nurse Midwives have their own provider types
Complete only one enrollment application regardless of number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
RN Supervision form

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Nurse Practitioner

PROVIDER TYPE: 41

Specialty: Pediatric
Specialty Code: 034
AND/OR

Specialty: Family
Specialty Code: 035
AND/OR

Specialty: General
Specialty Code: 335

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License (APN, CNS, NP, FNP, PNP)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Nurse-Midwife

PROVIDER TYPE: 22

Specialty: Nurse-Midwife
Specialty Code: 080

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Nursing Facility

PROVIDER TYPE: 20

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

ENROLLMENT TYPE: Facility

Each service location must complete a separate application and pay a separate application fee.
Nursing Facility service location addresses must be in Colorado, only in special cases are out of state service locations accepted.

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

PROVIDER TYPE: 21

Specialty: ICF/IID - Private
Specialty Code: 383
OR

Specialty: ICF/IID - State
Specialty Code: 394

ENROLLMENT TYPE: Facility

Each service location must complete a separate application and pay a separate application fee
Service location addresses must be in Colorado, only in special cases are out of state service locations accepted.

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Restricted

BT Allowed? Yes

Occupational Therapist

PROVIDER TYPE: 28

Specialty: Occupational Therapist
Specialty Code: 450

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Optical Outlet

PROVIDER TYPE: 08

Specialty: Optical Outlet
Specialty Code: 395

ENROLLMENT TYPE: Facility

Each service location must complete a separate application

Required ATTACHMENTS:

Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Optometrist

PROVIDER TYPE: 07

Specialty: Optometrist
Specialty Code: 183

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

Osteopath

PROVIDER TYPE: 26

Specialty: Osteopath
Specialty Code: 501

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

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 TYPE: 60

Specialty: Personal Care Agency
Specialty Code: 560

ENROLLMENT TYPE: Facility

Each service location must complete a separate application and pay a separate application fee
This provider type is only for pediatric personal care benefit members. Please visit the Personal Care benefit page more more information.
The closest NPI taxonomy code is Nursing & Custodial Care Facilities - Custodial Care Facility - 311Z00000X

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Pharmacist

PROVIDER TYPE: 75

Specialty: Pharmacist
Specialty Code: 750

ENROLLMENT TYPE: Individual within a Group – affiliates to a group and the group bills

Must affiliate to at least one Pharmacy (PT 09) and/or Indian Health Services (IHS) Pharmacy (PT 62); may affiliate to multiple Pharmacies or IHS Pharmacies on one enrollment application (if applicable).

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance (insurance policy can be for either the pharmacist or the pharmacy.)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Pharmacy

PROVIDER TYPE: 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. 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

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

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

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? Yes

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

ENROLLMENT TYPE: Facility

Each pharmacy service location must complete a separate application
Pharmacy with DME-(specialty code 462) must pay an application fee with each application
Each pharmacy service location must have a unique National Provider Identifier (NPI)
Pharmacy Dispensing Fee Addendum must be completed (part of the online application)

Required ATTACHMENTS:

Colorado Pharmacy License (Specialty 463 ONLY-license may be from other state if in a border town)
Copy of the individual physician’s license for the Rural Dispensing Physician Site ONLY
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Physical Therapist

PROVIDER TYPE: 17

Specialty: Physical Therapist
Specialty Code: 451

ENROLLMENT TYPE: Billing Individual - directly bills for themselves OR
Individual within a Group - affiliates to a group and the group bills

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Physician

PROVIDER TYPE: 05

Specialty: Physician
Specialty Code: 505

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Physician Assistant

PROVIDER TYPE: 39

Specialty: Physician Assistant
Specialty Code: 510

ENROLLMENT TYPE: Individual within a Group – affiliates to a group and the group bills

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Podiatrist

PROVIDER TYPE: 06

Specialty: Podiatrist
Specialty Code: 194

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification - for Billing Individual ONLY

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 TYPE: 30

Specialty: Psychiatric Residential Treatment Facility
Specialty Code: 476

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

Department of Human Services - Division of Child Welfare License (Out-of-state must submit licensure from own state)
Department of Human Services, Office of Behavioral Health Attestation Letter (Required for in-state providers only)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

QMB Benefits Only

PROVIDER TYPE: 18

Specialty: QMB Benefits Only
Specialty Code: 321

ENROLLMENT TYPE: Billing Individual – directly bills for themselves

This provider type is for Chiropractors only
Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Lawful Presence form and copy of Identification

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

Regional Accountable Entity (RAE)

PROVIDER TYPE: 85

Specialty: Regional Accountable Entity
Specialty Code: 850

ENROLLMENT TYPE: Atypical

Contract with the Department
Each region must complete a separate application
PCMP (Primary Care Medical Provider) staff (MD/DO, NP, PA, etc.) must enroll separately

Required ATTACHMENTS:

Colorado Division of Insurance specifically for either:
- Health Maintenance Organization (HMO), OR
- Limited Service Licensed Provider Network (LSLPN)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Registered Nurse

Special Instructions:

See Non-Physician Practitioner - Individual

Rehabilitation Agency

PROVIDER TYPE: 48

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

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

ENROLLMENT TYPE: Group

Practitioner specialty must have at least one enrolled, licensed physical, occupational, or speech therapist affiliated with the group
Comprehensive Outpatient Rehabilitation Facility specialty must have at least one enrolled, licensed practitioner (MD, DO, OD or DPM) affiliated with the group
For new enrollments, the group must be approved prior to enrollment of the individual practitioners
Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
Each service location must complete a separate application
Comprehensive Outpatient Rehabilitation Facility must pay an application fee with each application

Required ATTACHMENTS:

Copy of the individual license for the individual provider mentioned above who will affiliate to the group.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Residential Child Care Facility

PROVIDER TYPE: 52

Specialty: Mental Health Program
Specialty Code: 471

ENROLLMENT TYPE: Group

Must have at least one enrolled, licensed psychologist or physician affiliated with the group
For new enrollments, the group must be approved prior to enrollment of the individual practitioners
Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
Each service location must complete a separate application

Required ATTACHMENTS:

Department of Human Services Permanent 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)
Copy of the individual license for the physician or psychologist who will affiliate to the group
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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 TYPE: 45

Specialty: Hospital Based
Specialty Code: 398
OR

Specialty: Freestanding
Specialty Code: 472

ENROLLMENT TYPE: Group

Must have at least one enrolled, licensed physician, osteopath, advanced practice nurse or physician assistant affiliated with the clinic
For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners
Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the clinic
Each service location must complete a separate application

Required ATTACHMENTS:

Medicare Rate Sheet
Provider's Cost Report
Copy of the individual license for the physician, osteopath, advanced practice nurse or physician assistant who will affiliate to the clinic
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

School Health Services

PROVIDER TYPE: 51

Specialty: School Health Services
Specialty Code: 475

ENROLLMENT TYPE: Facility

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 ATTACHMENTS:

Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? No

BT Allowed? No

Speech Therapist

PROVIDER TYPE: 27

Specialty: Speech Therapist
Specialty Code: 452

Complete only one enrollment application regardless of enrollment type and number of service locations

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months) for Billing Individual ONLY
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months) for Billing Individual ONLY
Lawful Presence form and copy of Identification for Billing Individual ONLY

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 TYPE: 64

Specialty: Substance Use Disorder - Clinics
Specialty Code: 477

ENROLLMENT TYPE: Facility

Each location must complete a separate application.
SUD Clinics may only enroll if they are Supervised by:
- Health First Colorado-enrolled licensed health practitioners who are:
  - Advanced Practice Nurses
  - Physicians/Psychiatrists
  - Physician Assistants
  - AND one of the following:
    - Certified in addiction psychiatry by the American Board of Psychiatry and Neurology (ABPN)
    - 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), the American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine (ABPM); or
- Health First Colorado-enrolled licensed behavioral health clinicians who are:
  - Psychologists (PhD, PsyD, or EdD)
  - Licensed Clinical Social Workers (LCSW)
  - Licensed Professional Counselors (LPC)
  - Licensed Addiction Counselors (LAC)
  - Licensed Marriage and Family Therapists (LMFT)

Required ATTACHMENTS:

Department of Human Services Office of Behavioral Health License
Copy of the license (and certification as applicable) for the individual who will supervise the SUD clinic
Completed SUD Clinic Supervisor Attestation Form
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

ENROLLMENT TYPE: Facility

Each location must complete a separate application.
Must have an enrolled, approved, active provider type 64-SUD Clinic with specialty 477-SUD Clinic prior to approval of this specialty -OR- be enrolling for both 64/477 and this new specialty at the same time.

Required ATTACHMENTS:

Department of Human Services, Office of Behavioral Health Option Letter (specific to Special Connections)
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS. Services may be provided under the "Licensed Behavioral Health Clinician" Provider Type.

Supply

PROVIDER TYPE: 74

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

ENROLLMENT TYPE: Billing Individual – directly bills for themselves

Complete only one enrollment application

Required ATTACHMENTS:

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
Sales Tax Certificate 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 entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Lawful Presence form and copy of Identification

Risk Level: High

Fee Req'd? No

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

PROVIDER TYPE: 14

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

ENROLLMENT TYPE: Facility

Each service location must complete a separate application and pay a separate application 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 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
Sales Tax Certificate 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 entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

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
Sales Tax Certificate 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 entered on the application. If the address is not on the certificate, a screen print of the Sales Tax Account indicating matching service location address is acceptable.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: High

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? No

OOS Allowed? Yes

BT Allowed? Yes

Transportation

PROVIDER TYPE: 13 - Emergency Medical Transportation and Air Ambulance

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

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

ENROLLMENT TYPE: Facility

Each service location must complete a separate application

Required ATTACHMENTS:

Ambulance License
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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

ENROLLMENT TYPE: Facility

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

Required ATTACHMENTS:

Ambulance license
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Medicare Req'd? Yes

OOS Allowed? Yes

BT Allowed? Yes

PROVIDER TYPE: 73 - Non-Emergent Medical Transportation

Specialty: Non-Emergency Medical - Broker Network Participant
Specialty Code: 326

ENROLLMENT TYPE: Atypical

Each service location must complete a separate application
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 ATTACHMENTS:

PUC license or local county ambulance license, if applicable. To obtain a PUC Medicaid Transportation Permit (MCT) follow the directions outlined on the NEMT Provisional Agreement.
Proof of Malpractice/Liability Insurance

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

ENROLLMENT TYPE: Atypical

Each service location must complete a separate application
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 ATTACHMENTS:

PUC license or local county ambulance license, if applicable. To obtain a PUC Medicaid Transportation Permit (MCT) follow the directions outlined on the NEMT Provisional Agreement.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)
Lawful Presence form and copy of Identification for Individual/SSN enrollment ONLY

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 TYPE: 49

Specialty: X-Ray Facility
Specialty Code: 495

ENROLLMENT TYPE: Facility

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 ATTACHMENTS:

Department of Public Health and Environment RCD59-1 CE Report required for instate, service address must match the service location address in application. OOS must submit similar document or X-ray license from own state.
Proof of Malpractice/Liability Insurance
W9 (signed and dated within last 6 months)
Voided business check (no temporary checks or deposit slips) or bank letter (dated within last 6 months)

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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