A B C D E Provider Category Description Documentation ...
A
B
1
Provider Type
Description
C
Category Name
3
1 Air Ambulance
4
License Certification
6
2
Ambulance/Ambulette Services
License
Certification
7
9
3
Ambulatory Surgical Centers (ASC)
10
License Certification
4 Audiologist
123
License
14
Acupuncturist (non
Registration
5
physician) First Active Date
156
10/14/2003
Insurance
6 Admin Agents
17
Insurance
Anesthesiologist
7
Assistant (maps back to
MIIS as provider type 52)
Certificate of Registration
20
(Implemented 12/11/12)
Adult Day Care Facility
8
(maps back to MIIS as provider type 53)
Certification
22
(Implemented 12/11/12)
License
24
25
9
Doctor of Chiropractic (DC)
Certification
Insurance
26
D
E
Documentation Requirements Ohio Web Address
State Medical Transportation Board (if private) OR
Medicare Participation (if public/gov't)
State Medical Transportation Board (if private) OR
Medicare Participation (if public/gov't)
State Department of Health AND Medicare Participation State Speech and Hearing Professionals Board State Medical Board
Professional (Malpractice) Liability
Commercial Liability
(attest to malpractice insurance on the revised application dated 9/12/2012) Supervisory Approval Only, Only enrolled if admin agent for DEP Provider
State Medical Board
Ohio Deaprtment of Aging PASSPORT adult day care provider agreement.
Provider needs to send in certificate.
State Chiropractic Board Chiropractic Acupuncture (from Chiropractic Board)
Professional (Malpractice)Liabiltiy
Located on license if they have this certification. (attest to malpractice insurance on the revised application dated 9/12/2012)
A
B
1
Provider Type
Description
Alcohol & Drug
10
Counseling Clinic (free standing outpatient
facility only)
289
C
D
Category Name
Documentation Requirements
Applicable State
Department of
Alcohol & Drug
Addiction Services certificate to
Ohio Mental Health & Addiction Services
administer
treatment
programs
E
Ohio Web Address
30
11
Pain Clinic
331
12 Group Practice
33
Accreditation
CARF - Commission for Accreditation of Rehab Facilities (Free Standing)
Accreditation
Joint Commission on Accreditation of Healthcare Org (Hospital Based)
W9 and individual provider enrolled and/or certified
License
State Department of Health AND
35
36
13
ASC Arthroplasty Center Certification
Effective 5/1/2016
Medicare Participation AND
Completion of Application Addendum
This will be sent upon receipt of app to the ASC. Addendum reviewed by Credentialing before enrolled and certified.
3378
39
License
State Medical Board and
Accreditation
NCCPA - National Commission on Certification of Phys Asst OR
40
14
Physician Assistant First
Active Date 7/01/1999
Registration
DEA - Drug Enforcement (OPTIONAL)
Administration
41
A
B
1
Provider Type
Description
43
C
Category Name
License
15 Dentist
44
Registration
Insurance
45
48
Dialysis Center/ERSD
License
16 (End state Renal Disease)
free standing
Certification
5409
51
17
DME Supplier
If Registration
pharmacy license submitted
enroll as 64
52
Certification
54
Sleep Laboratory (Maps Certification
18 back to MIIS as provider type
45) (Implemented 12/11/12) Certification
5556
Independent Diagnostic
19
Testing Facility (Maps back Certification
to MIIS as provider type 45)
(implemented 12/11/12)
57
20 Occularist
5690
License
27 Hearing Aid Dealers
61
License
28 Certified Shoe Retailer Certification
63
D
E
Documentation Requirements Ohio Web Address
State Dental Board and
- Drug Enforcement Administration 4D46-9771-
3D83EC5D317A%7D/PageVars/Library/InfoManage/Guide.htm
Professional (Malpractice)Liabiltiy
(attest to malpractice insurance on the revised application dated 9/12/2012)
State Department of Health AND Medicare Participation
State Board of Pharmacy AND
Medicare Participation
American Academy of sleep Medicine AND
Provider needs to submit documentation.
Medicare Participation
Provider needs to submit documentation.
Medicare Participation as a Independent Diagnostic Testing Facility
Provider needs
to
submit documenation.
State Vision Professionals Board
State Speech and Hearing Professionals Board
PFA - Pedorthic Footwear Association
A
B
1
Provider Type
Description
6656
29
DHO ordered Home care provider (Caregiver)
67
68 30 Home Health Agency
C
Category Name
Accreditation Certification
Accreditation
69
71
32
Hospice First Active
License
4/01/1999 (maps back to MIIS
72
as a prov type 30)
Certification
74
License
D
E
Documentation Requirements Ohio Web Address
Supervisor approval only (requires DHO or SHO order)
Joint Commission on Accreditation of Healthcare Org. OR
Medicare Participation OR
CHAP - Community Health Accreditation Program
State Department of Health and Medicare Participation
State Board of Nursing AND
? ANCC - American Nurses
Credentialing Center OR,
? AANP - American Associatiation of
Nurse Practitioners Certification Board
33
Advanced practice Nurse
(Clinical Nurse Specialist and Certified Nurse Practitioner) First Active 7/01/1999
Accreditation
OR,
?
AACN American Association of Critical-
Care Nurses Certification Corporation
The Ohio Nursing Board license lookup verifies certification as advanced practice nurse
OR,
? NCC -
National Certification Corporation OR,
? PNC - Pediatric Nursing Certification
Board
76
Registration
DEA - Drug OPTIONAL
Enforcement
Administration
77
A
B
1
Provider Type
Description
79
80
34
Hospital General Acute (InPatient/OutPatient)
81
82
84
Hospital - PER DIEM 85 35 (DETOX INPATIENT
STAY) effective 2/1/2018
86 87
C
Category Name
Registration
Certification
Accreditation
D
E
Documentation Requirements Ohio Web Address
DEA AND
-
Drug
Enforcement
Administration
Medicare Participation OR
Joint Commission on Accreditation of Healthcare Org. OR
Accreditation
AOA HFAP ? Amer. Osteopathic Assn Healthcare Facilities Accred. Program
Facility has to send in certificate.
Registration Certification Accreditation Accreditation
DEA AND
-
Drug
Enforcement
Administration
Medicare Participation OR
Joint Commission on Accreditation of Healthcare Org. OR
AOA HFAP ? Amer. Osteopathic Assn Healthcare Facilities Accred. Program
Facility has to send in certificate.
A
B
1
Provider Type
Description
C
Category Name
89
90
36
Hospital - Psychiatric (inpatient/outpatient)
91
Registration
Certification Accreditation
Accreditation
9923
Registration
94
95
Certification
Hospital - Rehabilitation/
37
Long Term Acute Care
Accreditation
96
(inpatient/outpatient)
Accreditation
97
Accreditation
98
100
License
38
Mechanotherapist/ Doctor of Mechanotherapy (DMT) Insurance
101
D
E
Documentation Requirements Ohio Web Address
DEA AND
-
Drug
Enforcement
Administration
Medicare Participation OR
Joint Commission on Accreditation of Healthcare Org. OR
AOA HFAP ? Amer. Osteopathic Assn Healthcare Facilities Accred. Program
Facility has to send in certificate.
DEA AND
-
Drug
Enforcement
Administration
Medicare Participation OR
CARF ? Commission for Accreditation of Rehab Facilities OR
Joint Commission on Accreditation of
Healthcare Org.
OR
AOA HFAP ? Amer. Osteopathic Assn Healthcare Facilities Accred. Program
Facility has to send in certificate.
State Medical Board
Professional (Malpractice)
Liability (attest to malpractice insurance on the revised application dated 9/12/2012)
Hotel / Motel (must be
40
associated with a rehab, Traumatic Brain Injury (TBI) or
Plan/Program
Rehabilitation Plan- Supervisor approval
chronic pain facility)
1003
A
B
1
Provider Type
Description
C
Category Name
45 Laboratory (free standing) Certification
105
107
48
Massage Therapist / Massotherapist
109
License License
110
111
52
Certified Registered Nurse Anesthetist
Accreditation
Registration
1123
License
114
Nursing Home
115
53
or
Certification
Skilled nursing step-down
unit within a hospital
Accreditation
116
1178
Certification
119
56
Residential Care/Assisted License Living Facility First Active
Date: 8/01/2004
120
Certification
D
Documentation Requirements
CMS CLIA (Clinical Laboratory Improvement Amendments)
E
Ohio Web Address
State Medical Board
State Board of Nursing AND Natl Bd of Cert & Recert for Nurse Anesthetists (CRNAs) AND
DEA - Drug Enforcement Administration
(OPTIONAL)
ssionID={D15F4DBC-E6D1-4CE0-A73B-FD352E61766C}&SP=2
State Department of Health OR
Medicare Participation Joint Commission OR American Osteopathic Association (AOA) Medicare State Department of Health OR
Medicare
Accreditation.
IF AOA they need to submit the copy of
provider would need to submit
57 Occupational Therapist License
122
1245
58
Optician (Licensed
Dispensing Optician)
License
State Occupational Therapy, Physical Therapy & Athletic Trainers Board
State Vision Professionals Board
A
B
1
Provider Type
Description
126
59
Optometrist/Doctor of Optometry
112278
Other Third Party
Administrator (must be
private insurance company,
60
employer or other
organization requesting
reimbursement for medical
112390
services)
C
Category Name
License
Insurance
131 64 Pharmacy
132
Registration Registration
65 Physical Therapist
134
136
137
66
Doctor of Osteopathy (DO)
138
License License Registration Insurance
D
Documentation Requirements
State Vision Professionals Board
Professional (Malpractice) Liability
E
Ohio Web Address
(attest to malpractice insurance on the revised application dated 9/12/2012)
* by Supervisor approval only
- Drug Enforcement Administration 468B-8CFA-
761250872842%7D/PageVars/Library/InfoManage/Guide.htm
NCPDP - National Council for Prescription Drug Programs
Enrollments only sent to us through PBM - they must send verification/credentials
State Occupational Therapy, Physical Therapy & Athletic Trainers Board
State Medical Board and
DEA AND
-
Drug
Enforcement
Administration
Professional (Malpractice) Liability
(attest to malpractice insurance on the revised application dated 9/12/2012)
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