Provider Enrollment Types

Instructions for Step 2

Download an enrollment and revalidation checklist based on the Enrollment Type(s) associated with the chosen Provider Type from step 1.

Each section below represents an Enrollment Type. Not all Enrollment Types are available for all Provider Types. For example, a Pharmacy only has the option to enroll as a facility, while a Physician may enroll as either a Billing Individual, an Individual Within a Group, or an Ordering-Prescribing-Referring (OPR) Provider.

After downloading the checklist, proceed to step 3.

What is an Enrollment Type?

The Enrollment Type categorizes provider types to help identify additional enrollment requirements.

IMPORTANT: Select the Enrollment Type on the application as indicated below.

Enrollment Types

Atypical

  • Administrative Services Organization (ASO)(81)
  • Case Manager (including Community Centered Boards (CCB) and Intensive Case Managers) (11)
  • Health Maintenance Organization (HMO) (23)
  • Home and Community Based Service (HCBS) provider (This includes all waiver providers i.e. DD, SLS, BI, etc.) (36)
  • Regional Accountable Entity (RAE) (85)
  • Transportation (73) (Specialties 326 and 525)

Facility

  • Ambulatory Surgery Center (ASC) (44)
  • Community Clinic (86)
  • Dialysis Center (33)
  • Home Health (10)
  • Hospice (50)
  • Hospital - General (01)
  • Hospital - Mental (02)
  • Independent Laboratory (12)
  • Indian Health Services - Pharmacy (62)
  • Nursing Facility (20)
  • Nursing Facility - ICF/IID (21)
  • Optical Outlet (08)
  • Personal Care Agency (60)
  • Pharmacy (09)
  • Psychiatric Residential Treatment Facility (30)
  • School Health Services (51)
  • Substance Use Disorder - Clinic (64)
  • Supply (14) (Specialties 481 and 482)
  • Transportation (13) (Specialties 086, 124 and 324)
  • X-Ray Facility (49)

Group

  • Behavioral Therapy Clinic (83)
  • Birthing Center (58)
  • Clinic - Dental (47)
  • Clinic - Practitioner (16)
  • Community Mental Health Center (35)
  • Developmental Evaluation Clinic (46)
  • Federally Qualified Health Center (FQHC) (32)
  • Indian Health Services - FQHC (61)
  • Non-Physician Practitioner - Group (25)
  • Rehabilitation Agency (48)
  • Residential Child Care Facility (52)
  • Rural Health Clinic (45)

Individual within a Group

  • Foreign Teaching Physician (65)
  • Non-Physician Practitioner - Individual (24)
  • Physician Assistant (39)
  • Pharmacist (75)

Billing Individual or Individual Within a Group

The Provider Types below can enroll using either the Billing Individual or Individual Within a Group Enrollment Type. For further information regarding these Enrollment Types, please review the document Billing Individual vs Individual within a Group.

  • Audiologist (19)
  • Behavioral Therapist (84)
  • Certified Registered Nurse Anesthetist (CRNA) (40)
  • Dental Hygienist (66)
  • Dentist (04)
  • Licensed Behavioral Health Clinician(38)
  • Licensed Psychologist (37)
  • Nurse Practitioner (41)
  • Nurse-Midwife (22)
  • Occupational Therapist (28)
  • Optometrist (07)
  • Osteopath (26)
  • Physical Therapist (17)
  • Physician (05)
  • Podiatrist (06)
  • Speech Therapist (27)

Ordering-Prescribing-Referring (OPR)

 

IMPORTANT: OPR providers are only allowed to order, prescribe, or make referrals. OPR providers are not eligible to bill for services rendered.

  • Audiologist (19)
  • Certified Registered Nurse Anesthetist (CRNA) (40)
  • Dentist (04)
  • Licensed Psychologist (37)
  • Nurse Practitioner (41)
  • Nurse-Midwife (22)
  • Optometrist (07)
  • Osteopath (26)
  • Physician (05)
  • Podiatrist (06)
  • Speech Therapist (27)