PROVIDER TYPE CODE	

PROVIDER TYPE NAME	

ENROLLMENT TYPE	NATIONAL
PROVIDER INDENTIFER (NPI)	

ENROLLMENT FEE	

SITE VISIT	

RISK CATEGORY	
A3	COMMUNITY SERVICE AGENCY	FAO	R	R	R	MODERATE	

A4	
LIC INDEP SUBSTANCE ABUSE COUNS (LISAC)	
INDIVIDUAL	
R	
N	
N	
LIMIT	
A5	BEHAVIORAL HEALTH THERAPEUTIC HOME	FAO	R	R	N	LIMIT	
A5	BEHAVIORAL HEALTH THERAPEUTIC HOME	INDIVIDUAL	R	N	N	LIMIT	

A6	RURAL SUBSTANCE ABUSE TRANSITIONAL
AGCY	
FAO	
R	
R	
N	
LIMIT	
A8	IHR-INDIVIDUAL HOME RESPITE	FAO	R	R	N	LIMIT	

B1	
RESID TRTMENT CTR-SECURE (17+BEDS)(IMD)	
FAO	
R	
R	
N	
LIMIT	

B2	
RESID TRTMENT CTR-NON-SECURE (1-16 BEDS)	
FAO	
R	
R	
N	
LIMIT	

B3	
RESID TRTM CTR-NON-SECURE (17+BEDS)(IMD)	
FAO	
R	
R	
N	
LIMIT	
B5	SUBACUTE FACILITY (1-16 BEDS)	FAO	R	R	N	LIMIT	
B6	SUBACUTE FACILITY (17+BEDS)(IMD)	FAO	R	R	N	LIMIT	
B7	CRISIS SERVICES PROVIDER	FAO	R	R	N	LIMIT	

B8	
BEHAVIORAL HEALTH RESIDENTIAL FACILITY	
FAO	
R	
R	
N	
LIMIT	
BC	BOARD CERTIFIED BEHAVIOR ANALYST	INDIVIDUAL	R	N	N	LIMIT	

C2	
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)	
FAO	
R	
R	
N	
LIMIT	
C4	SPECIALITY PER DIEM HOSPITALS	FAO	R	N	N	LIMIT	
C5	638 FQHC	FAO	R	R	N	LIMIT	
E1	INDEPENDENT TESTING FACILITIES	FAO	R	R	N	LIMIT	
ED	FREE STANDING ED	FAO	R	N	N	LIMIT	
F1	FISCAL INTERMEDIARIES	ATYPICAL-FAO	N	R	N	LIMIT	
IC	INTEGRATED CLINICS	FAO	R	R	R	MODERATE	
NA	NEMT - NON-AMBULANCE AIR	ATYPICAL-FAO	N	R	N	LIMIT	
NE	NEMT - EQUINE	ATYPICAL-FAO	N	R	N	LIMIT	

NT	NEMT-TNC TRANSPORTATION NETWORK
COMPANY	
ATYPICAL-FAO	
N	
R	
R	
MODERATE	

SA	
SPEECH LANGUAGE PATHOLOGY ASSISTANT	
INDIVIDUAL	
R	
N	
N	
LIMIT	
TR	TREAT & REFER	ATYPICAL-FAO	N	R	R	MODERATE	
TS	TRAVEL SERVICES	ATYPICAL-FAO	N	N	N	LIMIT	
01	GROUP-PAYMENT ID	GROUP	R	N	N	LIMIT	
01	GROUP-PAYMENT ID	ATYPICAL-FAO	N	N	N	LIMIT	
02	HOSPITAL	FAO	R	R	N	LIMIT	
03	PHARMACY	FAO	R	R	N	LIMIT	
04	LABORATORY	FAO	R	R	R	MODERATE	
05	CLINIC	FAO	R	R	N	LIMIT	
06	EMERGENCY TRANSPORTATION	FAO	R	R	R	MODERATE	
07	DENTIST	INDIVIDUAL	R	N	N	LIMIT	
08	MD-PHYSICIAN	INDIVIDUAL	R	N	N	LIMIT	
09	CERTIFIED NURSE-MIDWIFE	INDIVIDUAL	R	N	N	LIMIT	
10	PODIATRIST	INDIVIDUAL	R	N	N	LIMIT	
11	PSYCHOLOGIST	INDIVIDUAL	R	N	N	LIMIT	

12	
CERTIFIED REGISTERED NURSE ANESTHETIST	
INDIVIDUAL	
R	
N	
N	
LIMIT	
13	OCCUPATIONAL THERAPIST	INDIVIDUAL	R	N	N	LIMIT	
14	PHYSICAL THERAPIST	INDIVIDUAL	R	N	R	MODERATE	
15	SPEECH/HEARING THERAPIST	INDIVIDUAL	R	N	N	LIMIT	
16	CHIROPRACTOR	INDIVIDUAL	R	N	N	LIMIT	
17	NATUROPATH PHYSICIAN	INDIVIDUAL	R	N	N	LIMIT	
18	PHYSICIANS ASSISTANT	INDIVIDUAL	R	N	N	LIMIT	
19	REGISTERED NURSE PRACTITIONER	INDIVIDUAL	R	N	N	LIMIT	
20	RESPIRATORY THERAPIST	INDIVIDUAL	R	N	N	LIMIT	
22	NURSING HOME	FAO	R	R	N	LIMIT	
23	HOME HEALTH AGENCY	FAO	R	R	R	HIGH	

25	
GROUP HOME (DEVELOPMENTALLY DISABLED)	
ATYPICAL-FAO	
N	
N	
N	
LIMIT	
27	ADULT DAY HEALTH	ATYPICAL-FAO	N	R	N	LIMIT	

PROVIDER TYPE CODE	

PROVIDER TYPE NAME	

ENROLLMENT TYPE	NATIONAL
PROVIDER INDENTIFER (NPI)	

ENROLLMENT FEE	

SITE VISIT	

RISK CATEGORY	

28	NON-EMERGENCY TRANSPORTATION
PROVIDERS	
ATYPICAL-FAO	
N	
R	
R	
MODERATE	
29	COMMUNITY/RURAL HEALTH CENTER	FAO	R	R	N	LIMIT	
30	DME SUPPLIER	FAO	R	R	R	HIGH	
31	DO-PHYSICIAN OSTEOPATH	INDIVIDUAL	R	N	N	LIMIT	
32	MEDICAL FOODS	ATYPICAL-FAO	N	R	N	LIMIT	
35	HOSPICE	FAO	R	R	R	MODERATE	
36	ASSISTED LIVING HOME (FORMERLY ACH)	ATYPICAL-FAO	N	R	N	LIMIT	
37	HOMEMAKER	ATYPICAL-INDIVIDUAL	N	N	N	LIMIT	
39	HABILITATION PROVIDER	ATYPICAL-FAO	N	R	N	LIMIT	
39	HABILITATION PROVIDER	ATYPICAL-INDIVIDUAL	N	N	N	LIMIT	
40	ATTENDANT CARE	ATYPICAL-FAO	N	R	R	MODERATE	
41	DIALYSIS CLINIC	FAO	R	R	N	LIMIT	
43	AMBULATORY SURGICAL CENTER	FAO	R	R	N	LIMIT	
44	ENVIRONMENTAL (LTC)	ATYPICAL-FAO	N	R	N	LIMIT	
46	NURSE (PRIVATE-RN/LPN)	INDIVIDUAL	R	N	N	LIMIT	
47	REGISTERED DIETICIAN	ATYPICAL-INDIVIDUAL	N	N	N	LIMIT	
48	NUTRITIONIST	ATYPICAL-INDIVIDUAL	N	N	N	LIMIT	
49	ASSISTED LIVING CENTER	ATYPICAL-FAO	N	R	N	LIMIT	
50	ADULT FOSTER CARE	ATYPICAL-FAO	N	N	N	LIMIT	
54	AFFILIATED DENTAL HYGIENIST	INDIVIDUAL	R	N	N	LIMIT	
55	HOTELS	ATYPICAL-FAO	N	R	N	LIMIT	
56	BOARDING HOME	ATYPICAL-FAO	N	R	N	LIMIT	
62	AUDIOLOGIST	INDIVIDUAL	R	N	N	LIMIT	
67	PERFUSIONIST	INDIVIDUAL	R	N	N	LIMIT	
68	HOMEOPATHIC	INDIVIDUAL	R	N	N	LIMIT	
69	OPTOMETRIST	INDIVIDUAL	R	N	N	LIMIT	
70	HOME DELIVERED MEALS	ATYPICAL-FAO	N	R	N	LIMIT	
71	PSYCHIATRIC HOSPITAL	FAO	R	R	N	LIMIT	
77	BH OUTPATIENT CLINIC	FAO	R	R	R	MODERATE	

78	MENTAL HEALTH RESIDENTIAL TREATMENT
CNTR	
FAO	
R	
R	
N	
LIMIT	
79	VISION CENTER	FAO	R	R	N	LIMIT	
81	EPD HCBS	ATYPICAL-FAO	N	R	N	LIMIT	
82	SURGICAL FIRST ASSISTANT	INDIVIDUAL	R	N	N	LIMIT	
83	FREE-STANDING BIRTHING CENTER	FAO	R	R	N	LIMIT	
84	LICENSED MIDWIFE	INDIVIDUAL	R	N	N	LIMIT	

85	
LICENSED CLINICAL SOCIAL WORKER (LCSW)	
INDIVIDUAL	
R	
N	
N	
LIMIT	

86	LICENSED MARRIAGE &
FAMILYTHERAPISTLMFT	
INDIVIDUAL	
R	
N	
N	
LIMIT	

87	
LICENSED PROFESSIONAL COUNSELOR (LPC)	
INDIVIDUAL	
R	
N	
N	
LIMIT	
92	SCHOOL BASED BUS TRANSPORTATION	ATYPICAL-FAO	N	R	N	LIMIT	
93	SCHOOL BASED ATTENDANT CARE	ATYPICAL-INDIVIDUAL	N	N	N	LIMIT	
94	SCHOOL BASED NURSE (RN/LPN)	INDIVIDUAL	R	N	N	LIMIT	

95	NON-MEDICARE CERTIFIED HOME HTH
AGENCIES	
FAO	
R	
R	
R	
HIGH	
97	AIR TRANSPORTATION	FAO	R	R	N	LIMIT