Information by Provider Type

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.
• Must enroll using the organization's federal Employer Identification Number (EIN).
• 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:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
  Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

  Adult Mental Health Residential

  Provider Type: 96

  Specialty: Supported Therapeutic Transitional Living
  Specialty Code: 561

  Enrollment Type: Facility

  • Each service location must complete a separate application and pay a separate fee.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

  Required Attachments:

  • A Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) license with an Adult Mental Health Transitional Living, Level 2 sub-endorsement.
  • W9 (signed and dated within the last 6 months).
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
  • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

  Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
  Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

  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.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

  Required Attachments:

  • License
  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

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

  • Complete only one enrollment application regardless of enrollment type and number of service locations.
  • Must enroll using the individual's Social Security Number (SSN).

  Required Attachments:

  • License
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment

  Additional Attachments for Billing Individuals ONLY:

  • W9 (signed and dated within the last 6 months)
  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID.

  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
  Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	Yes - with proof of a Colorado License

  Behavioral Health ASO

  Provider Type: 91

  Specialty: BHA Administrative Service Organization (ASO)
  Specialty Code: 900

  Enrollment Type: Atypical

  • Contract with the Department of Human Services, Behavioral Health Administration.
  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).
  • Rendering providers must be enrolled separately.

  Required Attachments:

  • W9 (signed and dated within the last 6 months)
  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
  Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

  Behavioral Health Crisis Line

  Provider Type: 88

  Specialty: Behavioral Health Crisis Line
  Specialty Code: 888

  Enrollment Type: Atypical

  • Each service location must complete a separate application.
  • Must enroll using the organization's federal Employer Identification Number (EIN).

  Required Attachments:

  • Proof of Colorado Crisis Services Crisis Line contract with the Colorado Department of Human Services (CDHS), Behavioral Health Administration (BHA)
    • Attach a copy of the contract page(s) that identify the applicant as a Colorado Crisis Services/Crisis Line contractor with CDHS BHA and the signature pages(s).

    Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

    Behavioral Health Crisis Services

    Provider Type: 95

    Specialty: Acute Treatment Unit (ATU)
    Specialty Code: 386

    Enrollment Type: Group

    • Each service location must complete a separate application.
    • Must enroll using the organization's federal Employer Identification Number (EIN).
    • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05), Physician Assistant (PT 39) or Osteopath (PT 26) affiliated with the group.
    • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
    • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

    Required Attachments:

    • Colorado Department of Public Health and Environment (CDPHE) Behavioral Health Entity (BHE) license with a Part 4(B) Acute Treatment Services endorsement or a Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) ATU license.
    • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician, physician assistant or osteopath who will affiliate to the group.
    • W9 (signed and dated within the last 6 months)
    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
    • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

    Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

    Specialty: Crisis Stabilization Unit (CSU)
    Specialty Code: 387

    Enrollment Type: Group

    • Each service location must complete a separate application.
    • Must enroll using the organization's federal Employer Identification Number (EIN).
    • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05), Physician Assistant (PT 39) or Osteopath (PT 26) affiliated with the group.
    • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
    • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

    Required Attachments:

    • Colorado Department of Public Health and Environment (CDPHE) Behavioral Health Entity (BHE) license with a Part 4(A) Crisis Stabilization Services endorsement or a Behavioral Health Administration (BHA) Behavioral Health Entity (BHE) CSU license.
    • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician, physician assistant or osteopath who will affiliate to the group.
    • W9 (signed and dated within the last 6 months)
    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
    • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

    Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

    Specialty: Mobile Crisis Response
    Specialty Code: 772

    Enrollment Type: Group

    • Each service location must complete a separate application.
    • Must enroll using the organization's federal Employer Identification Number (EIN).
    • Must have at least one licensed Psychologist (PhD, PsyD, EdD) (PT 37), Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) (PT 38), Nurse Practitioner (PT 41), Physician (PT 05) or Osteopath (PT 26) affiliated with the group.
    • Credentialed individuals (rendering providers) must be enrolled separately (separate application) and affiliated with the group.
    • For new enrollments, the group must be approved prior to enrollment of the licensed individual(s).

    Required Attachments:

    • Colorado Department of Human Services Behavioral Health Administration (BHA) license for mobile crisis response services.
    • Copy of the individual license for the psychologist, behavioral health clinician, nurse practitioner, physician or osteopath who will affiliate to the group.
    • W9 (signed and dated within the last 6 months)
    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
    • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

    Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

    Behavioral Health Group

    Provider Type:77

    Specialty: With Prescriber
    Specialty Code: 388
    OR
    Specialty: Without Prescriber
    Specialty Code: 389
    Enrollment Type: Group

    • Each service location must complete a separate application.
    • Must enroll using the organization's federal Employer Identification Number (EIN).
    • With Prescriber:
      • There must be at least one Physician (Provider Type [PT] 05), Osteopath (PT 26), Physician Assistant (PT 39) or Nurse Practitioner (PT 41) AND at least one Licensed Psychologist (PT 37) or Licensed Behavioral Health Clinician (PT 38) who will affiliate with the group. (There must be two copies of licenses attached with the application, one for the Physician, Osteopath, Physician Assistant or Nurse Practitioner AND one for the Licensed Psychologist or Licensed Behavioral Health Clinician who will affiliate with the group.)
      • Only Licensed Psychologists (PT 37) and Licensed Behavioral Health Clinicians (PT 38) are allowed to affiliate with this specialty. (There must be one copy of the license attached with the application for the Licensed Psychologist or Licensed Behavioral Health Clinician.)

      Required Attachments:

      • Copy(ies) of the individual license(s) as indicated above for the rendering individual(s) who will affiliate to the group.
      • W9 (signed and dated within the last 6 months)
      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
      • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

      Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
      Medicare Req'd?	No	OOS Allowed?	With Prescriber = Yes Without Prescriber = No	BT Allowed?	Yes

      Behavioral Health MSO

      Provider Type: 92

      Specialty: BHA Managed Service Organization (MSO)
      Specialty Code: 899

      Enrollment Type: Atypical

      • Contract with the Department of Human Services, Behavioral Health Administration
      • Each service location must complete a separate application.
      • Must enroll using the organization's federal Employer Identification Number (EIN).
      • Rendering providers must be enrolled separately.

      Required Attachments:

      • W9 (signed and dated within the last 6 months)
      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

      Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
      Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

      Behavioral Health Secure Transportation

      Provider Type: 97
      Specialty: Secure Transportation
      Specialty Code: 773

      Enrollment Type: Atypical

      • Each service location must complete a separate application.
      • Must enroll using the organization's federal Employer Identification Number (EIN).

      Required Attachments:

      • Board of County Commissioners license for secure transportation services for each county of operation.
      • Board of County Commissioners vehicle permit for each vehicle.
      • W9 (signed and dated within the last 6 months)
      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
      • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

      Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
      Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

      Behavioral Therapy - Clinic

      Provider Type: 83
      Please read the definition below before choosing this provider type.

      Specialty: Behavioral Therapy Clinic
      Specialty Code: 830

      Enrollment Type: Group

      Important: If you are a Behavioral Health provider serving individuals with mental illness and/or substance use disorders, do not select this provider type. Refer to the information for Non-Physician Practitioner Groups (25) and/or Substance Use Disorder Clinics (64).

      Definition: Services for children/youth under age 21 who have an autism spectrum disorder or similar condition: Health First Colorado Criteria for Behavioral Therapy

      • Individual practitioners must have specialized qualifications as shown here: Behavioral Therapy Provider Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
      • Additional resources are available on the Pediatric Behavioral Therapies web page.
      • Each service location must complete a separate application.
      • Must enroll using the organization's federal Employer Identification Number (EIN).
      • 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, or Provider Type 38, Specialty 521-Licensed Behavioral Health Clinician.
      • For new enrollments, the clinic must be approved prior to enrollment of the individual practitioners.
      • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

      Required Attachments:

      • W9 (signed and dated within the last 6 months)
      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
      • Completed Behavioral Therapy Provider Attestation Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, for the Behavioral Therapist (PT 84) who will affiliate with the clinic. Attach evidence of license, credential, training and/or experience as indicated in the form. (Note: Submission of the Attestation Form is not required for Provider Type 37 - Licensed Psychologist or Provider Type 38 - Licensed Behavioral Health Clinician who may be affiliating to the clinic.)
      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

      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
      Please read the definition below before choosing this provider type.

      Specialty: Behavioral Therapist
      Specialty Code: 831

      Definition: Services for children/youth under age 21 who have an autism spectrum disorder or similar condition: Health First Colorado Criteria for Behavioral Therapy

      • Individual practitioners must have specialized qualifications as shown here: Behavioral Therapy Provider Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
      • Additional resources are available on the Pediatric Behavioral Therapies web page.

      Important: If you are a Behavioral Health provider serving individuals with mental illness and/or substance use disorders, do not select this provider type. Refer to information for Licensed Behavioral Health Clinicians (38) or Licensed Psychologists (37).

      Enrollment Type: Individual within a Group - affiliates to a group and the group bills, OR

      Billing Individual: Bills directly for themselves.

      • Complete only one enrollment application regardless of enrollment type and number of service locations.
      • Must enroll using the individual's Social Security Number (SSN).
      • Individual within a Group enrollment may only affiliate with a Behavioral Therapy Clinic.
      • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

      Required Attachments:

      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.
      • Behavioral Therapy Provider Attestation Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, must be completed.
        • Evidence of license, credential, training and/or experience must be included, e.g. BCBA accreditation.

        Additional Attachments for Billing Individual only:

        • W9 (signed and dated within the last 6 months)
        • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
        • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

        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 Information web page for additional information regarding TPIDs.

        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.
        • Must enroll using the organization's federal Employer Identification Number (EIN).

        Required Attachments:

        • Facility License issued by the Colorado Department of Public Health & Environment (CDPHE)
        • W9 (signed and dated within the last 6 months)
        • Voided business check (no temporary checks or deposit slips) or bank letter (signed and dated within the last 6 months)
        • Copy of the individual license for the Certified Nurse Midwife (CNM) or Physician who will affiliate to the Birthing Center
        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

        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.
        • Must enroll using the organization's federal Employer Identification Number (EIN).
        • EFT Exemption Instructions located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, (to bypass the Electronic Funds Transfer (EFT) requirement)

        Required Attachments:

        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

        Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
        Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

        Specialty: Targeted Case Management/Transition Services (TCM/TS)
        Specialty Code: 770

        Enrollment Type: Atypical

        • Each service location must complete a separate application.
        • Must enroll using the organization's federal Employer Identification Number (EIN).

        Required Attachments:

        • Completed Case Management Agency Application specifically for TCM Transition Coordination
        • W9 (signed and dated within the last 6 months)
        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

        Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
        Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

        Specialty: Targeted Case Management/HCBS (TCM/HCBS)
        Specialty Code: 771

        Enrollment Type: Atypical

        • Each service location must complete a separate application.
        • Must enroll using the organization's federal Employer Identification Number (EIN).

        Required Attachments:

        • The Notice of Intent to Award for Solicitation letter.
        • W9 (signed and dated within the last 6 months)
          • Address must match one address listed on the application.
          • DBA (Trade Name) must be listed on Line 2 if included on the application.
          • Voided check or bank letter address must match an address on the application.
          • If a bank letter is submitted, the letter must be signed by the bank within the last six months.
            • Must include account and routing numbers.

            Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
            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 is not also a licensed health professional (advanced practice nurse, physician/psychiatrist, physician assistant, licensed addiction counselor).

            Provider Type: 80
            Specialty: Certified Midwife
            Specialty Code: 211

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

            • Complete only one enrollment application regardless of enrollment type and number of service locations.
            • Must enroll using the individual's Social Security Number (SSN).

            Required Attachments:

            • License
            • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

            Additional Attachments for Billing Individuals Only:

            • W9 (signed and dated within the last 6 months).
            • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
            • Affidavit of Lawful Presence Form, which can be found on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

            Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
            Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

            Certified Registered Nurse Anesthetist (CRNA)

            Provider Type: 40

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

            Enrollment Type: Individual within a Group - affiliates to a group and the group bills

            Billing Individual - bills directly for themselves
            OR
            Ordering, Prescribing, Referring - limited to Ordering/Prescribing/Referring

            • Complete only one enrollment application regardless of enrollment type and number of service locations.
            • Must enroll using the individual's Social Security Number (SSN).

            Required Attachments:

            • License
            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

            Additional Attachments for Billing Individuals only:

            • W9 (signed and dated within the last 6 months)
            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

            Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
            Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

            Chiropractor - QMB

            Provider Type: 18
            Specialty: Chiropractor-QMB
            Specialty Code: 321

            Enrollment Type: Billing Individual – directly bills for themselves

            • This provider type is for Chiropractors for the Qualified Medicare Beneficiary (QMB) program only.
            • Complete only one enrollment application regardless of enrollment type and number of service locations.
            • Must enroll using the individual's Social Security Number (SSN).

            Required Attachments:

            • License
            • W9 (signed and dated within the last 6 months)
            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and copy of identification
            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

            Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
            Medicare Req'd?	Yes	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

              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
              • W9 (signed and dated within the last 6 months)
              • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
              • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

              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
              OR
              Specialty: Telemedicine
              Specialty Code: 878

              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.
              • Must enroll using the organization's federal Employer Identification Number (EIN).
              • Each service location must complete a separate application.
                • The Clinic-Practitioner specialty must enter a physical address for the service location address in the application.
                • The Telemedicine specialty may list a PO Box for the service location address in the application. (Please enter the PO Box in one of the following accepted formats: Box XXXX, PO XXXX, Post Office XXXX or POB XXXX.)

                Required Attachments:

                • Copy of the individual license for the MD, DO, OD or DPM who will affiliate to the clinic
                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                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 Freestanding Emergency Dep.
                Specialty Code: 860

                Enrollment Type: Facility

                • Each service location must complete a separate application.
                • Must enroll using the organization's federal Employer Identification Number (EIN).
                • 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 The Joint Commission (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
                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                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

                THIS PROVIDER TYPE IS NO LONGER AVAILABLE FOR NEW ENROLLMENTS AS OF July 1, 2024. The Community Mental Health Center provider type is being replaced by the Comprehensive Safety Net Provider. Please review the requirements indicated for the Comprehensive Safety Net Provider.

                Community Support Services Provider

                Provider Type: 89

                Specialty: Recovery Support Services Organization
                Specialty Code: 889

                Enrollment Type: Group

                • Must have at least one enrolled, licensed practitioner (PT 05-Physician, PT 26-Osteopath, PT 41-Nurse Practitioner, PT 39-Physician Assistant, PT 37 Licensed Psychologist (PhD, PsyD, EdD) or PT 38- Licensed Behavioral Health Clinician [ACD/LAC, CSW, LPC, MFT]) affiliated with the organization.
                • For new enrollments, the organization must be approved prior to enrollment of the individual practitioners.
                • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the organization.
                • Each service location must complete a separate application.
                • Must enroll using the organization's federal Employer Identification Number (EIN).
                • A contract with a Regional Accountable Entity (RAE) is required after the enrollment is approved.

                Required Attachments:

                • Department of Human Services, Behavioral Health Administration (BHA) License as a Recovery Support Services Organization.
                • Copy of the individual license for the Physician, Osteopath, Nurse Practitioner, Physician Assistant, Licensed Psychologist (PhD, PsyD, EdD) or Licensed Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) who will affiliate to the organization.
                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

                Specialty: Supportive Housing Provider
                Specialty Code: 208

                Enrollment Type: Group

                • Must have at least one enrolled behavioral health provider PT 37 Licensed Psychologist (PhD, PsyD, EdD) or PT 38- Licensed Behavioral Health Clinician (ACD/LAC, CSW, LPC, MFT) affiliated with the group.
                • For new enrollments, the organization must be approved prior to enrollment of the individual practitioners.
                • Credentialed professionals (rendering providers) must be enrolled individually (separate application) and affiliated with the organization.
                • Each service location must complete a separate application.
                • Must enroll using the organization's federal Employer Identification Number (EIN).

                Required Attachments:

                • Colorado Department of Local Affairs (DOLA) Division of Housing (DOH) Memorandum with certification number and approval as a Supportive Housing Provider. (Complete the Certification data in the application.)
                • Copy of the individual license for the Licensed Psychologist or Licensed Behavioral Health Clinician who will affiliate to the group.
                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

                Comprehensive Safety Net Provider

                Provider Type: 78

                Specialty: Comprehensive Community Behavioral Health Provider
                Specialty Code: 887

                Enrollment Type: Group

                • Each service location must complete a separate application and pay a separate application fee.
                • Must enroll using the organization's federal Employer Identification Number (EIN).
                • Must have at least one enrolled, licensed Physician (Provider Type 05), Osteopath (Provider Type 26), Licensed Behavioral Health Clinician (Provider Type 38), or Licensed Psychologist (Provider Type 37) affiliated with the group.
                • Credentialed individuals (rendering providers) must be enrolled individually (separate application) and affiliated with the group.
                • For new enrollments, the group must be approved prior to enrollment of the individual practitioners.

                Required Attachments:

                • Behavioral Health Administration license as a Behavioral Health Entity. (Attach a copy of the current license and complete the license information in the application.)
                • Behavioral Health Administration approval letter as a Comprehensive Provider. (Attach a copy of the current approval letter and enter the information in the license section of the application.)
                • Copy of the individual’s license (indicated above), who will affiliate to the group.
                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

                Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
                Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	Yes

                Dental Hygienist

                Provider Type: 66
                Specialty: Dental Hygienist
                Specialty Code: 066

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

                • Complete only one enrollment application regardless of enrollment type and number of service locations.
                • Must enroll using the individual's Social Security Number (SSN).

                Required Attachments:

                • License
                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment

                Additional Attachments For Billing Individuals Only:

                • W9 (signed and dated within the last 6 months)
                • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                Dental Therapist

                Provider Type: 98
                Specialty: Dental Therapist
                Specialty Code: 776

                Enrollment Type: Individual within a Group - affiliates to a group and the group bills
                OR
                Billing Individual – bills directly for themselves

                • Individuals complete only one enrollment application regardless of enrollment type and number of service locations.
                • Must enroll using the individual's Social Security Number (SSN).

                Required Attachments:

                • License (Attach a copy of current license and complete the license information.)
                • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

                Additional Attachments for Billing Individuals Only:

                • W9 (signed and dated within the last 6 months)
                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                Provider Type: 04

                Specialty: Oral Surgery
                Specialty Code: 061
                OR Specialty: Dentist
                Specialty Code: 062
                OR Specialty: Orthodontist
                Specialty Code: 063

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

                • Complete only one enrollment application regardless of enrollment type and number of service locations
                • Must enroll using the individual's Social Security Number (SSN).

                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.

                  Additional Attachments For Billing Individuals Only:

                  • W9 (signed and dated within the last 6 months)
                  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                  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 drop-down list; there is not a dermatology option listed here.

                    Provider Type: 46
                    Specialty: Developmental Evaluation Clinic
                    Specialty Code: 370

                    Enrollment Type: Group

                    • Each location must complete a separate application.
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • 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
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    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.
                    • Must enroll using the organization's federal Employer Identification Number (EIN).

                    Required Attachments:

                    • License
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                    Medicare Req'd?	Yes	OOS Allowed?	No	BT Allowed?	Yes

                    Direct Entry or Certified Professional Midwife

                    Provider Type: 69

                    Specialty: DEM/CPM
                    Specialty Code: 361

                    Enrollment Type: Individual within a Group - affiliates to a group and the group bills

                    • Individuals complete only one enrollment application and must affiliate to at least one enrolled Birthing Center. Multiple affiliations can be indicated in the application when applicable. (Affiliations to other groups/clinics are not acceptable.)
                    • Must enroll using the individual's Social Security Number (SSN).

                    Required Attachments:

                    • License
                    • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

                    Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                    Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                    Provider Type: 79
                    Specialty: Doula
                    Specialty Code: 210

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

                    • Individuals complete only one enrollment application regardless of enrollment type and number of service locations.
                    • Must enroll using the individual's Social Security Number (SSN).

                    Required Attachments:

                    • Completed Doula Provider Attestation Form and supporting documents.
                    • Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

                    Additional Attachments for Billing Individuals Only:

                    • W9 (signed and dated within the last 6 months).
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
                    • Affidavit of Lawful Presence form, located on the Provider Forms web page under the Provider Enrollment and Update Forms dropdown, and a government-issued photo ID.

                    Risk Level:	High	Fee Req'd?	No	NPI Req'd?	Yes
                    Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                    Durable Medical Equipment (DME)
                    • Refer to 'Supply Facility', 'Supply Billing Individual', or 'Pharmacy (Pharmacy with DME)'.

                    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. 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.
                    • Must enroll using the organization's federal Employer Identification Number (EIN).

                    Required Attachments:

                    • The Health Resources and Services Administration (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.
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                    Medicare Req'd?	No	OOS Allowed?	Yes (Only for Specialties 150 and 160)	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.
                    • Must enroll using the individual's Social Security Number (SSN).

                    Required Attachments:

                    • License
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    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)/Preferred Provider Organization (PPO)

                    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
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • Credentialed professionals (rendering, ordering, prescribing and referring providers) in HMO networks must be enrolled individually (separate application)

                    Required Attachments:

                    • License from the Colorado Division of Insurance - HMO Specialty 391 ONLY
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    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

                    Specialty: D-SNP HMO/PPO (Dual Special Needs Programs)
                    Specialty Code: 400

                    • Contract with the Department
                    • Each service location must complete a separate application
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • Credentialed professionals (rendering, ordering, prescribing and referring providers) in HMO networks must be enrolled individually (separate application)
                    • Border towns and out-of-state locations are allowed on a case-by-case basis with State approval.
                    • This specialty is stand alone (cannot be combined with other specialties) and an NPI is not allowed due to reporting requirements.

                    Required Attachments:

                    • License from the Colorado Division of Insurance
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    Risk Level	Limited	Fee Req'd?	No	NPI Req'd?	No
                    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

                    Home & Community Based Services (HCBS)

                    Provider Type: 36 Special Instructions:

                    Provider Type: 10
                    Specialty: Home Health
                    Specialty Code: 385

                    Enrollment Type: Facility

                    This specialty includes Home Health and Private Duty Nursing.

                    • Each service location must complete a separate application and pay a separate application fee.
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • Electronic Visit Verification (EVV) is required with this enrollment and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid program). Visit the EVV web page for additional information.

                    Required Attachments:

                    • In-state providers must possess a Class A Home Health Agency license issued from the Colorado Department of Public Health and Environment.
                    • Out-of-state providers must possess a Home Health Agency license issued by their own state.
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    Risk Level:	High	Fee Req'd?	Yes	NPI Req'd?	Yes
                    Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                    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
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • Effective 7/1/2024, Electronic Visit Verification (EVV) is no longer required for Hospice providers.

                    Required Attachments:

                    • License (License must include the service location address)
                    • W9 (signed and dated within the last 6 months)
                    • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                    • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                    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.
                    • Must enroll using the organization's federal Employer Identification Number (EIN).
                    • Distinct Part Units (DPUs) are not recognized separately from the General Hospital under which they are licensed and are not enrolled separately.

                    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). Clinical Laboratory Improvement Amendments (CLIA) may be waived if this OCL does not do laboratory testing.

                      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.
                      • Must enroll using the organization's federal Employer Identification Number (EIN).
                      • 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: A copy of the current CLIA certificate must be attached.
                      • Proof of The Joint Commission (JCAHO) accreditation (optional)
                      • W9 (signed and dated within the last 6 months)
                      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                      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.
                      • Must enroll using the organization's federal Employer Identification Number (EIN).

                      Required Attachments:

                      • Clinical Laboratory Improvement Amendments (CLIA) certificate
                      • W9 (signed and dated within the last 6 months)
                      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                      Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
                      Medicare Req'd?	No	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 notrequired 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).
                      • Must enroll using the organization's federal Employer Identification Number (EIN).
                      • Credentialed professionals (the rendering providers) must be enrolled individually (separate application) and affiliated with the group.

                      Required Attachments:

                      • The Health Resources and Services Administration (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 the last 6 months)
                      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Insurance information must be entered in the application. Federal Tort Claims Act (FTCA) is acceptable in lieu of malpractice/liability. Proof of coverage is not a required attachment.

                      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.
                      • Must enroll using the organization's federal Employer Identification Number (EIN).
                      • 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:

                      • W9 (signed and dated within the last 6 months)
                      • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                      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.

                      Provider Type: 38
                      Specialty: Licensed Behavioral Health Clinician
                      Specialty Code: 521

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

                      • Complete only one enrollment application regardless of enrollment type and number of service locations
                      • Must enroll using the individual's Social Security Number (SSN).
                      • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                      Required Attachments:

                      • License (ACD/LAC, CSW, LPC, or MFT)
                      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                      ADDITIONAL ATTACHMENTS for BILLING INDIVIDUAL ONLY:

                      • W9 (signed and dated within the last 6 months)
                      • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                      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.

                      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.

                      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.

                      Provider Type: 37
                      Specialty: Licensed Psychologist (PhD, PsyD, EdD)
                      Specialty Code: 520

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

                      • Complete only one enrollment application regardless of enrollment type and number of service locations.
                      • Must enroll using the individual's Social Security Number (SSN).
                      • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                      Required Attachments:

                      • License
                      • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                      Additional Attachments For Billing Individuals Only:

                      • W9 (signed and dated within the last 6 months)
                      • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                      • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                      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. Review the specific requirements for these provider types to verify which is applicable.
                      • For the application process to be completed, a minimum of three (3) 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.
                        • Enrollment Type: Atypical
                        • Provider Type: 73 – Transportation
                        • Specialty Code: Non-emergency medical (525)
                        • Enrollment Type: Facility
                        • Provider Type: 13 – Transportation
                        • Specialty Code: County Agency, Non Metro Area (124)

                        Special Instructions:

                        • Refer to the provider type 'Health Maintenance Organization (HMO)'

                        Provider Type: 90

                        Specialty: Histocompatibility Laboratory
                        Specialty Code: 890

                        Enrollment Type: Facility

                        • Each service location must complete a separate application and pay a separate application fee.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Clinical Laboratory Improvement Amendments (CLIA) certificate
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Home Infusion Therapy Supplier
                        Specialty Code: 891

                        Enrollment Type: Facility

                        • Each service location must complete a separate application and pay a separate application fee.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Accreditation as a Home Infusion Therapy Supplier
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Independent Diagnostic Testing Facility
                        Specialty Code: 897

                        Enrollment Type: Facility

                        • Each service location must complete a separate application and pay a separate application fee.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Copy of the License for the Supervising Physician
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Mammography Screening Center
                        Specialty Code: 893

                        Enrollment Type: Facility

                        • Each service location must complete a separate application and pay a separate application fee.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Food and Drug Administration (FDA) valid provisional certificate or valid certificate as a Mammography Screening Center.
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Medicare Diabetes Prevention Program Supplier
                        Specialty Code: 895

                        Enrollment Type: Facility

                        • Each service location must complete a separate application.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Medicare Diabetes Prevention Program (MDPP) preliminary recognition (as defined at 42 CFR § 424.205(c)(1)) or full recognition as determined by the Center for Disease Control and Prevention's (CDC) Diabetes Prevention Recognition Program (DPRP).
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	High	Fee Req'd?	No	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Medicare Only Hospital
                        Specialty Code: 892

                        Enrollment Type: Facility

                        • Each service location must complete a separate application and pay a separate application fee.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • Clinical Laboratory Improvement Amendments (CLIA) certificate
                        • W9 (signed and dated within the last 6 months)
                        • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                        • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                        Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                        Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                        Specialty: Opioid Treatment Program
                        Specialty Code: 898 High Risk depending on Substance Abuse and Mental Health Services Administration (SAMHSA) certification
                        896 Moderate Risk depending on SAMHSA certification

                        Enrollment Type: Facility

                        • Each service location must complete a separate application.
                        • Must enroll using the organization's federal Employer Identification Number (EIN).

                        Required Attachments:

                        • SAMHSA certification for an Opioid Treatment Program
                          • Not fully and continuously certified since 10/24/2018 = high risk level.
                          • Fully and continuously certified since 10/24/2018 = moderate risk level.

                          Risk Level:	High or Moderate depending on SAMHSA Certification	Fee Req'd?	No	NPI Req'd?	Yes
                          Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                          Specialty: Religious Non-Medical Health Care Institution
                          Specialty Code: 894

                          Enrollment Type: Facility

                          • Each service location must complete a separate application and pay a separate application fee.
                          • Must enroll using the organization's federal Employer Identification Number (EIN).

                          Required Attachments:

                          • W9 (signed and dated within the last 6 months)
                          • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                          • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                          Risk Level:	Limited	Fee Req'd?	Yes	NPI Req'd?	Yes
                          Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes

                          Non-Physician Practitioner - Group

                          Provider Type: 25
                          Specialty: Non-Physician Practitioner - Group
                          Specialty Code: 441
                          OR
                          Specialty: Telemedicine
                          Specialty Code: 878

                          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 or Audiologist.
                          • 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.
                          • Must enroll using the organization's federal Employer Identification Number (EIN).
                          • Each service location must complete a separate application.
                            • The Non-Physician Practitioner Group specialty must enter a physical address for the service location address in the application.
                            • The Telemedicine specialty may list a PO Box for the service location address in the application. (Please enter the PO Box in one of the following accepted formats: Box XXXX, PO XXXX, Post Office XXXX or POB XXXX.)

                            Required Attachments:

                            • Copy of the individual license/certification/attestation form for the individual provider mentioned above who will affiliate to the Group
                            • W9 (signed and dated within the last 6 months)
                            • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            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.
                            • Must enroll using the individual's Social Security Number (SSN).
                            • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                            Required Attachments:

                            • License
                            • RN Supervision Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            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

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

                            • Complete only one enrollment application regardless of enrollment type and number of service locations.
                            • Must enroll using the individual's Social Security Number (SSN).

                            Required Attachments:

                            • License (APN, CNS, NP, FNP, PNP)
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            Additional Attachments For Billing Individuals Only:

                            • W9 (signed and dated within the last 6 months)
                            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                            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

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

                            • Complete only one enrollment application regardless of enrollment type and number of service locations.
                            • Must enroll using the individual's Social Security Number (SSN).

                            Required Attachments:

                            • License
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            Additional Attachments For Billing Individuals Only:

                            • W9 (signed and dated within the last 6 months)
                            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                            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.
                            • Must enroll using the organization's federal Employer Identification Number (EIN).
                            • 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 the last 6 months)
                            • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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.
                            • Must enroll using the organization's federal Employer Identification Number (EIN).
                            • 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 the last 6 months)
                            • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the 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

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

                            • Complete only one enrollment application regardless of enrollment type and number of service locations.
                            • Must enroll using the individual's Social Security Number (SSN).
                            • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information..

                            Required Attachments:

                            • License
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            Additional Attachments For Billing Individuals Only:

                            • W9 (signed and dated within the last 6 months)
                            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                            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.
                            • Must enroll using the organization's federal Employer Identification Number (EIN).

                            Required Attachments:

                            • W9 (signed and dated within the last 6 months)
                            • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            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

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

                            • Complete only one enrollment application regardless of enrollment type and number of service locations.
                            • Must enroll using the individual's Social Security Number (SSN).

                            Required Attachments:

                            • License
                            • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                            Additional Attachments For Billing Individuals Only:

                            • W9 (signed and dated within the last 6 months)
                            • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                            • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                            Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                            Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                            Provider Type: 26
                            Specialty: Osteopath
                            Specialty Code: 501

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

                            • Complete only one enrollment application regardless of enrollment type and number of service locations.
                            • Must enroll using the individual's Social Security Number (SSN).

                            Required Attachments:

                            • License
                              • Active-duty military physicians providing services as part of official duties to Medicaid members at a military facility may have a license from another state and are not required to have a Colorado license.

                              Additional Attachments For Billing Individuals Only:

                              • W9 (signed and dated within the last 6 months)
                              • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                              • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                              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.
                              • Must enroll using the organization's federal Employer Identification Number (EIN).
                              • This provider type is only for pediatric personal care benefit members. Refer to the Pediatric Personal Care Billing Manual for more information.
                              • The closest NPI taxonomy code is Nursing & Custodial Care Facilities - Custodial Care Facility - 311Z00000X.
                              • Electronic Visit Verification (EVV) is required with this enrollment and will be automatically added with an approved application for Health First Colorado (Colorado's Medicaid program). Visit the EVV web page for additional information.

                              Required Attachments:

                              • License
                              • W9 (signed and dated within the last 6 months)
                              • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                              • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                              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), Indian Health Services (IHS) Pharmacy (PT 62), Federally Qualified Health Center (PT 32) or Clinic - Practitioner (PT 16); may affiliate to multiple pharmacies and/or practitioner clinics on one enrollment application (if applicable).
                              • Must enroll using the individual's Social Security Number (SSN).

                              Required Attachments:

                              • License
                              • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                              Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                              Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                              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 that 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

                              OR 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

                              OR 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

                              OR 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.
                              • Must enroll using the organization's federal Employer Identification Number (EIN).
                              • 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).
                              • Pharmacy with DME (462) ONLY - Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                              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
                              • W9 (signed and dated within the last 6 months)
                              • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                              • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                              Provider Type: 17

                              Specialty: Physical Therapist
                              Specialty Code: 451

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

                              • Complete only one enrollment application regardless of enrollment type and number of service locations.
                              • Must enroll using the individual's Social Security Number (SSN).
                              • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                              Required Attachments:

                              • License
                              • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                              Additional Attachments For Billing Individuals Only:

                              • W9 (signed and dated within the last 6 months)
                              • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                              • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                              Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
                              Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                              Provider Type: 05
                              Specialty: Physician
                              Specialty Code: 505

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

                              • Complete only one enrollment application regardless of enrollment type and number of service locations.
                              • Must enroll using the individual's Social Security Number (SSN).

                              Osteopaths (DO): Do not select this provider type. Osteopaths must select Provider Type 26/501.

                              Required Attachments:

                              • License
                                • Active-duty military physicians providing services as part of official duties to Medicaid members at a military facility may have a license from another state and are not required to have a Colorado license.

                                Additional Attachments For Billing Individuals Only:

                                • W9 (signed and dated within the last 6 months)
                                • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

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

                                • Complete only one enrollment application regardless of enrollment type and number of service locations.
                                • Must enroll using the individual's Social Security Number (SSN).

                                Required Attachments:

                                • License
                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                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

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

                                • Complete only one enrollment application regardless of enrollment type and number of service locations.
                                • Must enroll using the individual's Social Security Number (SSN).

                                Required Attachments:

                                • License
                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                Additional Attachments For Billing Individuals Only:

                                • W9 (signed and dated within the last 6 months)
                                • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                                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.
                                • Must enroll using the organization's federal Employer Identification Number (EIN).

                                Required Attachments:

                                • Department of Human Services - Division of Child Welfare License as a Psychiatric Residential Treatment Facility (Required for in-state providers only.)
                                • Department of Human Services, Office of Early Childhood, Division of Early Care and Learning, Time Limited Child Care License indicating Service Type as: Residential Child Care Facility. (Required for in-state providers only.)
                                • Department of Human Services, Behavioral Health Administration (BHA) (previously known as the Office of Behavioral Health) Attestation Letter (Required for in-state providers only.)
                                • Psychiatric Residential Treatment Facilities (PRTFs) located in another state must submit all license and certification requirements for a PRTF in the state in which it is located.
                                • Accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.
                                • Provide an attestation indicating the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in 10 CCR 2505-10 Section 8.765.6.F and in federal law.
                                • W9 (signed and dated within the last 6 months)
                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                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 does not meet Masters- or Doctorate-level education requirements.

                                Provider Type: 68
                                Specialty: Qualified Residential Treatment Program (QRTP)
                                Specialty Code: 689

                                Enrollment Type: Facility

                                • Each service location must complete a separate application.
                                • Must enroll using the organization's federal Employer Identification Number (EIN).
                                • A QRTP cannot be enrolled as a Residential Child Care Facility (RCCF-provider type 52) at the same time.

                                Required Attachments:

                                • Department of Human Services, Office of Early Childhood, Division of Early Care and Learning, Time Limited Child Care License indicating Service Type as: Qualified Residential Treatment Program.
                                • Accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or Council on Accreditation of Services for Families and Children.
                                • Attestation Form for Facilities Enrolling with Health First Colorado (RCCF & QRTP), located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, must be completed and attached for in state only.
                                • W9 (signed and dated within the last 6 months).
                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months).
                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                                Medicare Req'd?	No	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.
                                • Must enroll using the organization's federal Employer Identification Number (EIN).
                                • 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)

                                  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:

                                  • Refer to Non-Physician Practitioner - Individual

                                  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

                                  OR 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.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).
                                  • Comprehensive Outpatient Rehabilitation Facility must pay an application fee with each application.
                                  • Practitioner (397) only - Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                                  Required Attachments:

                                  • Copy of the individual license for the individual provider mentioned above who will affiliate to the group.
                                  • W9 (signed and dated within the last 6 months)
                                  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  Provider Type: 52
                                  Specialty: Mental Health Program
                                  Specialty Code: 471
                                  Enrollment Type: Group

                                  • A Residential Child Care Facility (RCCF) cannot be enrolled as a Qualified Residential Treatment Program (QRTP - Provider Type 68) at the same time as an RCCF enrollment.
                                  • 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.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).

                                  Required Attachments:

                                  • Department of Human Services, Office of Early Childhood, Division of Early Care and Learning, Time Limited 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 clinic
                                  • W9 (signed and dated within the last 6 months)
                                  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  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 and pay a separate application fee.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).

                                  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
                                  • W9 (signed and dated within the last 6 months)
                                  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  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

                                  • Each school district must complete a separate application.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).
                                  • 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. Indicate "CFO" or "Superintendent" following the listed individual's name.

                                  Required Attachments:

                                  • W9 (signed and dated within the last 6 months)
                                  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                                  Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	No

                                  School Speech Therapist

                                  Provider Type: 42
                                  Specialty: School Health Services
                                  Specialty Code: 777

                                  Enrollment Type: Individual within a Group - affiliates to a group and the group bills

                                  • Individuals complete only one enrollment application and must affiliate to at least one enrolled School Health Services organization. Multiple affiliations can be indicated in the application when applicable. (Affiliations to other groups/clinics are not acceptable.)
                                  • Must enroll using the individual's Social Security Number (SSN).

                                  Required Attachments:

                                  • Colorado Department of Education (CDE) License with a Speech Therapist Endorsement. (Attach a copy of current license and complete the license information.)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  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

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

                                  • Complete only one enrollment application regardless of enrollment type and number of service locations.
                                  • Must enroll using the individual's Social Security Number (SSN).
                                  • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.

                                  Required Attachments:

                                  • License
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  Additional Attachments For Billing Individuals Only:

                                  • W9 (signed and dated within the last 6 months)
                                  • Voided check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Affidavit of Lawful Presence Form, located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down, and government-issued photo ID

                                  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                                  Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                                  Substance Use Disorder (SUD) Continuum

                                  Provider Type: 64
                                  

                                  Specialty	Specialty Code
                                  ASAM Level 2.5 Partial Hospitalization Program (PHP)	212
                                  ASAM Level 1.0	371
                                  ASAM Level 1 WM	372
                                  ASAM Level 2.1 IOP	373
                                  ASAM Level 2 WM	374
                                  ASAM Level 3.1	871
                                  ASAM Level 3.3	872
                                  ASAM Level 3.5	873
                                  ASAM Level 3.7	874
                                  ASAM Level 3.2 WM	875
                                  ASAM Level 3.7 WM	876

                                  Enrollment Type: Facility

                                  • Each location must complete a separate application.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).
                                  • Individual licensed practitioners must enroll separately.
                                  • When applicable, out-of-state or bordering town locations must contract with a Regional Accountable Entity for single case agreements.

                                  Required Attachments:

                                  • Department of Human Services Behavioral Health Administration (BHA) license with each appropriate ASAM level indicated.
                                  • W9 (signed and dated within the last 6 months)
                                  • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                  • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                  Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
                                  Medicare Req'd?	No	OOS Allowed?	Not allowed for ASAM Levels 2.5 PHP, 1.0, 1 WM, 2.1 IOP or out-of-state 2 WM

                                  Specialty	Specialty Code
                                  ASAM Level 1.7 Opioid Treatment Provider (OTP) Fully and continuously SAMSHA certified since 10/23/2018. Moderate Risk	213
                                  ASAM Level 1.7 Opioid Treatment Provider (OTP) Not fully and continuously SAMSHA certified since 10/23/2018. High Risk	214

                                  Enrollment Type: Facility

                                  • Each location must complete a separate application.
                                  • Must enroll using the organization's federal Employer Identification Number (EIN).
                                  • Individual licensed practitioners must enroll separately.
                                  • When applicable, out of state or bordering town locations must contract with a Regional Accountable Entity for single case agreements.

                                  Required Attachments:

                                  • Department of Human Services Behavioral Health Administration (BHA) license with ASAM Level 1 WM indicated.
                                  • Department of Human Services Behavioral Health Administration (BHA) license for a Controlled Substance Provider.
                                  • SAMHSA certification for an Opioid Treatment Program
                                    • Fully and continuously certified since 10/23/2018 = moderate risk level.
                                    • Not fully and continuously certified since 10/23/2018 = high risk level.

                                    Risk Level:	High or Moderate depending on SAMHSA Certification	Fee Req'd?	No	NPI Req'd?	Yes
                                    Medicare Req'd?	No	OOS Allowed?	No	BT Allowed?	Yes

                                    Specialty: Substance Use Disorder-Clinics
                                    Specialty Code: 477

                                    Effective August 1, 2024, no new enrollments are allowed for Specialty 477 Substance Use Disorder-Clinics.

                                    Specialty: Special Connections
                                    Specialty Code: 870

                                    Effective January 1, 2024, no new enrollments are allowed for Special Connections.

                                    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.

                                    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.
                                    • Must enroll using the individual's Social Security Number (SSN).
                                    • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) benefit manager at Haylee.Rodgers@state.co.us prior to submitting an enrollment application. Include a contact name and phone number.

                                    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
                                        • Screenprint from the accreditation agency's website

                                        Risk Level:	High	Fee Req'd?	No	NPI Req'd?	Yes
                                        Medicare Req'd?	No	OOS Allowed?	Conditional	BT Allowed?	Conditional

                                        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
                                        • Must enroll using the organization's federal Employer Identification Number (EIN).
                                        • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
                                        • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the DMEPOS benefit manager at Haylee.Rodgers@state.co.us prior to submitting an enrollment application. Please include a contact name and phone number.

                                        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
                                            • Screenprint from the accreditation agency's website

                                            Risk Level:	High	Fee Req'd?	Yes	NPI Req'd?	Yes
                                            Medicare Req'd?	No	OOS Allowed?	Conditional	BT Allowed?	Conditional

                                            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
                                            • Must enroll using the organization's federal Employer Identification Number (EIN).
                                            • Electronic Visit Verification (EVV) is optional with this enrollment. To participate in EVV, providers are required to complete and attach the Electronic Visit Verification Attestation Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down. Visit the EVV web page for additional information.
                                            • Note: Out of State service locations must provide products that are not available from an in-state provider. For product review, email a list of products to the DMEPOS benefit manager at Haylee.Rodgers@state.co.us prior to submitting an enrollment application. Please include a contact name and phone number.

                                            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
                                                • Screenprint from the accreditation agency's website

                                                Risk Level:	High	Fee Req'd?	Yes	NPI Req'd?	Yes
                                                Medicare Req'd?	No	OOS Allowed?	Conditional	BT Allowed?	Conditional

                                                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.
                                                • Must enroll using the organization's federal Employer Identification Number (EIN).

                                                Required Attachments:

                                                • License
                                                • W9 (signed and dated within the last 6 months)
                                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                                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.
                                                • Must enroll using the organization's federal Employer Identification Number (EIN).

                                                Required Attachments:

                                                • Ambulance License
                                                • W9 (signed and dated within the last 6 months)
                                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                                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.
                                                • Must enroll using the organization's federal Employer Identification Number (EIN).

                                                Required Attachments:

                                                • Ambulance license
                                                • W9 (signed and dated within the last 6 months)
                                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                                Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
                                                Medicare Req'd?	No	OOS Allowed?	Yes	BT Allowed?	Yes

                                                Provider Type: 73 - Non-Emergent Medical Transportation
                                                The state has imposed a moratorium on new enrollments for non-emergency medical transportation due to a significant potential for fraud, waste, or abuse to the Medicaid program in accordance with 42 CFR 455.470. An extension of a maximum of six months was requested and approved by CMS, effective April 1, 2024.
                                                

                                                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.
                                                • Must enroll using the organization's federal Employer Identification Number (EIN).
                                                • 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.
                                                • W9 (signed and dated within the last 6 months)
                                                • Voided business check (no temporary checks or deposit slips) or bank letter (dated within the last 6 months)
                                                • Malpractice/Liability insurance information must be entered in the application; however, proof of insurance is not a required attachment.

                                                Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
                                                Medicare Req'd?	Yes	OOS Allowed?	Yes	BT Allowed?	Yes