Behavioral Health Outpatient Treatment (Provider Type 14)
To see which documents must be submitted with your Provider Enrollment Packet, click the name of your provider specialty in the list below. Out of state providers must also submit proof of Medicaid eligibility in the state that services are/were rendered.
| Specialty | Description | Updated Date |
|---|---|---|
| 814 | Behavioral Health Community Network Entity/Agency/Group | 03/18/2024 |
| 300 | Qualified Mental Health Professional (QMHP) | 07/28/2022 |
| 301 | Qualified Mental Health Associate (QMHA) | 02/26/2024 |
| 302 | Qualified Behavioral Aide (QBA) | 02/26/2024 |
| 305 | Licensed Clinical Social Worker, Specialty 305 | 10/15/2019 |
| 306 | Licensed Marriage and Family Therapist, Specialty 306 | 10/15/2019 |
| 307 | Clinical Professional Counselor, Specialty 307 | 10/15/2019 |
| 308 | Day Treatment Model, Specialty 308 | 05/26/2020 |
Return to Provider Enrollment Checklists page.
If you have any questions, please contact the Provider Enrollment Unit at (877) 638-3472 from 8:00AM to 5:00PM, Monday through Friday.