Standard App

Standard Application

  • EIN only (except as indicated below)
  • Billing/direct pay entity with IRS reporting

The provider type you have selected indicates you should complete the Standard Provider Application.

Download the Standard Provider Application by clicking this link

 

 

 

Standard Provider Application enrollment most often requires the use of a federal Employer Identification Number (EIN). This is a direct pay, or billing entity, where reimbursements are reported to the IRS under the EIN, with a few exceptions. Enrollment using an EIN usually requires at least one association, or affiliation, with the individual that will directly see or evaluate the Colorado Medicaid member. The direct pay entity usually submits claims on behalf of the rendering individual where appropriate.

Please find your applicable provider type and access all documentation needed below: 

Provider Type

Checklist

Additional Documenation

Ambulatory Surgical Center Checkmark for the checklist linked  
Audiologist (SSN) Checkmark for the checklist linked  
Behavioral Health Organization Checkmark for the checklist linked  
Case Manager Checkmark for the checklist linked  
Certified Registered Nurse Anesthetist (SSN) Checkmark for the checklist linked  
Chiropractor (SSN) Checkmark for the checklist linked  
Community Mental Health Clinic Checkmark for the checklist linked  
Dental Clinic Checkmark for the checklist linked  
Dental Hygienist (SSN) Checkmark for the checklist linked  
Dentist (SSN) Checkmark for the checklist linked  
Developmental Evaluation Clinic Checkmark for the checklist linked  
Dialysis Center Checkmark for the checklist linked  
Family Planning Clinic Checkmark for the checklist linked  
Federally Qualified Health Center (FQHC) Checkmark for the checklist linked  → Prenatal Plus Program Participation Form 
HCBS Developmental Disabilities (EIN or SSN depending on service)    
HCBS BI/EBD/CMHS/CHCBS/CLLI/CWA Services (EIN or SSN depending on service)    
Health Maintenance Organization (HMO) Checkmark for the checklist linked  
Home Health Checkmark for the checklist linked Home Health Letter
Insurance Requirements
Hospice Checkmark for the checklist linked  
Hospital (General or Mental) Checkmark for the checklist linked Enrollment for New Hospitals
Independent Laboratory Checkmark for the checklist linked  
Non-Physician Practitioner Group Checkmark for the checklist linked  
Nursing Facility Checkmark for the checklist linked  → ICF/IID Enrollment Process
Nurse-Midwife (SSN) Checkmark for the checklist linked  
Nurse Practitioner (SSN) Checkmark for the checklist linked  
Occupational Therapist (SSN) Checkmark for the checklist linked  
Optician/Optical Outlet Checkmark for the checklist linked  
Optometrist (SSN) Checkmark for the checklist linked  
Organized Health Clinic Checkmark for the checklist linked  → Prenatal Plus Program Participation Form
Orthodontist (SSN) Checkmark for the checklist linked  
Osteopath (SSN) Checkmark for the checklist linked  

Outpatient Substance Use Disorder 
♦ Clinic (EIN)      ♦ Individual (SSN)

Clinic 
Individual

 Important enrollment information for behavioral health services
Pharmacy Checkmark for the checklist linked Out of State Letter
Dispensing Fee Attestation Form
Physical Therapist (SSN) Checkmark for the checklist linked  
Physician (SSN) Checkmark for the checklist linked  
Podiatrist (SSN) Checkmark for the checklist linked  
Psychiatric Residential Treatment Facility Checkmark for the checklist linked  
Psychologist (MA) (SSN) Checkmark for the checklist linked  Important enrollment information for behavioral health services
Psychologist (PhD) (SSN) Checkmark for the checklist linked Important enrollment information for behavioral health services
Regional Care Coordination Organization (RCCO) Checkmark for the checklist linked RCCO Contact Information
RCCO Map
Rehabilitation Agency (CORF or Practitioner) Checkmark for the checklist linked  
Residential Child Care Facility (RCCF) Checkmark for the checklist linked  
Rural Health Center Checkmark for the checklist linked  → Prenatal Plus Program Participation Form
School Health Services Checkmark for the checklist linked  
Speech Therapist (SSN) Checkmark for the checklist linked  
Supply Business
♦ Business (EIN)     ♦ Individual (SSN)
Business
Individual
Out of State Letter
Transportation (EIN or SSN for non-emergent, EIN for all others) Checkmark for the checklist linked  
X-Ray Facility Checkmark for the checklist linked  

For further assistance please contact: Xerox State Healthcare Provider Services Call Center 1-800-237-0757