Online Site for Enrollment

  • Providers will need to create a password for each application
  • Each online provider enrollment application is assigned a unique Application Tracking Number (ATN)
  • Providers will be able to resume a previously started application or check status of a submitted application
  • Provider Type and Provider Specialties that are able to be submitted into the portal for CCRI is listed below.
  • CCRI Short Form will be required if the service is already enrolled as a state plan service
  • Comprehensive list that includes every combination of procedure code and modifier for the PT/PS

Electronic Provider Enrollment Application

Provider Enrollment Information
Includes information regarding requirements for each Provider Type and links to the Department’s provider enrollment forms

Department of Human Services Website

MAB 99-14-06 – Re-enrollment/Revalidation of Medical Assistance (MA) Providers

Provider Enrollment Questions
Includes contact information and help for MA Providers