Revalidation Information for Home & Community-Based Services (HCBS) Providers

Instructions for HCBS Providers

The federal regulation at 42 CFR § 455.414 requires that state Medicaid agencies revalidate the enrollment of all providers, regardless of provider types and/or specialties, at least every 5 years.

When revalidating businesses (EIN enrollment) that have more than one service location, a separate revalidation for each different location is required.

If a fee is required, it is applicable to each service location. Please review the specialty information below to determine if the fee is required.

Individuals (SSN enrollment) complete only one revalidation.

Note: New specialties are not available to be added during a revalidation. If applicable they can be added via a maintenance request once revalidation is finalized and approved.

Before beginning a revalidation through the Provider Portal, please take a minute to review the:

Revalidation Quick Guide

After reviewing the training materials, log into the Provider Web Portal to begin revalidation.

Terms and Definitions

RISK LEVEL

Each specialty is designated as low, moderate, or high risk.

FEE REQ’D?

The specialty indicates if a fee is required by federal or state regulation.

NPI REQ’D?

The specialty is required to have a National Provider Identifier (NPI).

TAX ID REQ’D?

The specialty allows a business using a federal Employer Identification Number (EIN), or an individual using a Social Security Number (SSN).

OOS ALLOWED?

(Out-of-state (OOS) enrollment allowed?) The specialty allows for out-of-state service locations.

BT ALLOWED?

(Border town (BT) enrollment allowed?) the specialty allows the service location to be in an approved border town. Please see Appendix F for a list of approved border towns.

HCBS Service Provided

Adapted Therapeutic Recreational Equipment/Fees - CES

Specialty Code: 600

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Adult Day Services BI/EBD/SCI/CMHS

Specialty Code: 601

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Alternative Care Facility EBD/CMHS

Specialty Code: 602

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)
License (attach a copy of current license and complete the license information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Assistive Technology BI

Specialty Code: 603

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

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? Yes

BT Allowed? Yes

Assistive Technology CES/SLS

Specialty Code: 607

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? No

Behavioral Programming BI

Specialty Code: 609

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
- Must submit applicable licensure for Program Director to include Licensed Psychologist or LCSW, PT, OT, SLP, RN or Masters level Psychologist.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Behavioral Services CCT-DD/SLS

Specialty Code: 719

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Behavioral Services DD/SLS

Specialty Code: 610

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Board Certified Behavioral Analyst (BCBA) Certificate
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Behavioral Therapies, Autism CWA

Specialty Code: 611

THIS HCBS WAIVER ENDED JUNE 30, 2018 AND THE SPECIALTY IS NO LONGER AVAILABLE FOR ENROLLMENTS. Services may be provided under the Behavioral Therapy provider types.

Caregiver Education - CCT-DD/SLS

Specialty Code: 704

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Caregiver Education CCT-BI/EBD/CMHS

Specialty Code: 612

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Children with LLI - Massage Therapy CLLI

Specialty Code: 613

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.
For businesses other than sole-proprietors, the enrolling provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services, and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

A massage license through Colorado Department of Regulatory Agencies (DORA) is required for each individual performing services. Out of state providers must ALSO provide a massage license from their appropriate state agency, along with their Colorado DORA license.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)
EIN enrollments - Home Care Agency Class A license or Hospice license is optional.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Children with LLI - Palliative/Supportive Care CLLI

Specialty Code: 614

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Children with LLI - Respite (Skilled) CLLI

Specialty Code: 615

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Children with LLI - Respite (Unskilled) CLLI

Specialty Code: 616

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Children with LLI - Therapy and Counseling CLLI

Specialty Code: 617

For businesses other than sole-proprietors, the provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services, and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation.
Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License or Music Therapist Certification for each individual providing services
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Children's Case Management CHCBS

Specialty Code: 618

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Children's Habilitation Residential Program (CHRP)

Specialty Code: 619

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Community Connector CES

Specialty Code: 634

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Community Mental Health Services BI

Specialty Code: 635

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Commission on Rehabilitation Counselor Certification
Proof of certification or licensure or Curriculum Vitae or resume for Master's or Doctoral level counselor, outlining mental health counseling, experience and education.
License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Community Transition Services CCT-BI/EBD/CMHS

Specialty Code: 637

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Community Transition Services CCT-DD/SLS

Specialty Code: 705

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? Yes

Community Transition Services EBD

Specialty Code: 636

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Complementary and Integrative Health SCI

Specialty Code: 638

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license for the applicable Acupuncturist, Chiropractor, and/or Massage Therapist, and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Day Habilitation - Specialized Habilitation DD/SLS

Specialty Code: 639

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Day Habilitation - Specialized Habilitation-CCT-DD/SLS

Specialty Code: 722

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Day Habilitation-Supported Comm Conn CCT-DD/SLS

Specialty Code: 640

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Day Habilitation-Supported Comm Conn-DD/SLS

Specialty Code: 713

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Day Treatment BI

Specialty Code: 641

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Electronic Monitoring BI/EBD/SCI/CMHS

Specialty Code: 643

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Expressive Therapy - Art/Play CLLI

Specialty Code: 645

At least one year of experience in the provision of art or play therapy to pediatric/adolescent clients.
Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.
For businesses other than sole-proprietors, the enrolling provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services, and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
- License from the Colorado Department of Public Health and Environment if license is for Home Health Agency or Hospice Agency.
- License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Social Worker (LSW), Licensed Independent Social Worker (LISW), or Licensed Psychologist OR Non-denominational/spiritual/bereavement counselor/chaplain certification
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Expressive Therapy - Music Therapy CLLI

Specialty Code: 646

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Certification from the Certification Board for Music Therapists.
For businesses other than sole-proprietors, the provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

FMS/Cnsmr Drct Atndnt Sprt Svc BI/EBD/CMHS/SCI/SLS

Specialty Code: 702

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? Yes

Home Accessibility Adaptations - CES/SLS

Specialty Code: 648

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Contractor's License for municipalities served
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Home Delivered Meals CCT-BI/EBD/CMHS

Specialty Code: 649

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License to operate a retail food establishment (attach a copy of current license and complete the license information in revalidation)
Credentials of Dietetic Technician and/or Registered Dietitian
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? Yes

BT Allowed? Yes

Home Modifications Adaptations BI/EBD/SCI/CMHS

Specialty Code: 651

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Contractor's license (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Homemaker CES/SLS

Specialty Code: 652

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Homemaker- CCT-SLS

Specialty Code: 723

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

In-Home Support Services EBD/SCI/CHCBS

Specialty Code: 656

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

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Independent Living Skills Training BI

Specialty Code: 654

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Intensive Case Management CCT-BI/EBD/CMHS

Specialty Code: 658

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Intensive Case Management CCT-DD/SLS

Specialty Code: 709

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? Yes

Mentorship SLS

Specialty Code: 659

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Mentorship-CCT-SLS

Specialty Code: 715

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Non-Medical Transportation BI/EBD/SCI/CMHS

Specialty Code: 660

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

PUC license, if applicable (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Non-Medical Transportation DD/SLS

Specialty Code: 661

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

PUC license, if applicable (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Non-Medical Transportation-CCT-DD-SLS

Specialty Code: 716

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Parent Education CES

Specialty Code: 662

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Limited

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Peer Mentorship CCT-BI/EBD/CMHS

Specialty Code: 663

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Peer Mentorship CCT-DD

Specialty Code: 707

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Personal Care CES/SLS

Specialty Code: 664

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
- CDPHE Home Care Agency (HCA) Class A or Class B license only required if providing hands-on care in the member's home and the agency has more than one employee.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Personal Care-CCT-SLS

Specialty Code: 724

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Personal Care/Homemaker Services BI/EBD/SCI/CMHS

Specialty Code: 666

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

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Personal Care/Homemaker Services CCT-BI/EBD/CMHS

Specialty Code: 748

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

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Personal Emergency Response SLS

Specialty Code: 668

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Prevocational Services DD/SLS

Specialty Code: 669

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Approval from the Colorado Department of Public Health and Environment.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Prevocational Services-CCT-DD/SLS

Specialty Code: 721

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services - Hippotherapy CES/SLS

Specialty Code: 670

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

AHCB Hippotherapy Certification or Hippotherapy Clinical Specialist Certification
License (attach a copy of current license and complete the license information in revalidation) for each individual providing services
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services - Movement Therapy CES/SLS

Specialty Code: 672

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Board Certified Music Therapist certification or Dance Therapy certification (attach a copy of the certificate and complete the information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services-Hippotherapy-CCT-SLS

Specialty Code: 718

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services-Massage-CCT-SLS

Specialty Code: 730

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services-Massage-SLS-CES

Specialty Code: 729

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation) for each individual providing services
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Professional Services-Movement Therapy-CCT-SLS

Specialty Code: 726

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Residential Habilitation Services - Group Home DD

Specialty Code: 673

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Residential Habilitation Services-IRSS/Host Home DD

Specialty Code: 674

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Residential Habilitation Services-IRSS/Host Home CCT-DD

Specialty Code: 737

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Residential Habilitation Srvcs-Group Home-CCT-DD

Specialty Code: 734

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Respite BI/EBD/SCI/CMHS

Specialty Code: 675

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Respite CES/SLS

Specialty Code: 676

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation.
Colorado Department of Public Health and Environment Home Care Agency (HCA) Class A or Class B license only required if providing hands-on care in the member's home and the agency has more than one employee.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Respite-CCT-SLS

Specialty Code: 727

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Specialized Med Equipment/Supplies CES/DD/SLS

Specialty Code: 677

Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
Individuals (SSN enrollment) complete only one revalidation.
If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? Yes

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? Yes

BT Allowed? Yes

Substance Abuse Counseling BI

Specialty Code: 678

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

For businesses other than sole-proprietors, the provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation.
License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Supported Employment CCT-DD/SLS

Specialty Code: 731

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Supported Employment DD/SLS

Specialty Code: 679

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation)

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Supported Living Program BI

Specialty Code: 680

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Assisted Living License from CDPHE (attach a copy of current license and complete the license information in revalidation)
Certification (attach a copy of current CDPHE Supported Living Program certification)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Transitional Behavioral Hlth Sprts CCT-BI/EBD/CMHS

Specialty Code: 681

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Commission on Rehabilitation Counselor Certification
For businesses other than sole-proprietors, the provider must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation.
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

Transitional Living Program BI

Specialty Code: 682

Each service location must complete a separate revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? No

Tax ID Req'd: EIN

OOS Allowed? No

BT Allowed? No

Vehicle Modifications CES/SLS

Specialty Code: 685

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Vision DD/SLS

Specialty Code: 687

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

License (attach a copy of current license and complete the license information in revalidation)
Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Limited

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? Yes

Youth Day Services

Specialty Code: 751

Each business (EIN enrollment) service location must complete a separate revalidation.
Individuals (SSN enrollment) complete only one revalidation.

REQUIRED CERTIFICATIONS AND/OR LICENSES:

Insurance (attach a copy of current insurance and complete the insurance information in revalidation.

Risk Level: Moderate

Fee Req'd? No

NPI Req'd? Yes

Tax ID Req'd: SSN or EIN

OOS Allowed? No

BT Allowed? No

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