pdn-medicaid-provider-enrollment - Provider Enrollment Information

Sep 19, 2026

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Provider Enrollment Information for Oregon Medicaid (Oregon Health Plan) outlines requirements for health care providers serving medically fragile or intensive in-home services to apply for a National Provider Identifier (NPI) and related taxonomy. It instructs providers on using the NPPES website or requesting paper applications, and provides eligibility and payment prerequisites. The document also details enrollment request selection, definitions for payable individuals versus organizations, disclosure requirements for identifying and tax reporting, submission instructions, and guidance on required forms and outdated-form rejection.

LanguageEnglish

CategoryForms

FormatPDF

Pages18

Reading Time6 min

AccessFree to download

Provider Enrollment Information

What is this request for?

Definitions and enrollment information

Payable Individuals and Organizations

General information

Disclosure information

Instructions for submitting forms

Tina Kotek, Governor Department of Human Services Office of Developmental Disabilities Services 500 Summber St NE E-09 Salem, OR 97301-1073 Voice: 503-399-9300 Fax 503-378-5756 To: RNs, LPNs and Agencies As a Health Care Provider, providing services to children in the Medically Fragile Children’s Unit (MFCU) or Children’s Intensive In-Home Services (CIIS), you are a Medicaid health care provider and will be required to apply for an NPI and Taxonomy code. The NPI is a 10-digit, numeric identifier that does not expire or change and is administered by the Centers for Medicare & Medicaid Services (CMS) . Apply for your NPI at the National Plan and Provider Enumeration System (NPPES) website [https://nppes.cms.hhs.gov/\#/](https://nppes.cms.hhs.gov/#/ . You may also call)[ . You may also call](https://nppes.cms.hhs.gov/#/ . You may also call) the NPIEnumerator at 1-800-465-3203 and request a paper NPI application form. You MUST have an NPI number in order to be paid by CIIS. Once you have received your NPI number please notify me at 971-388-9300 or [CIIS.providers@odhsoha.oregon.gov](CIIS.providers@odhsoha.oregon.gov) . If you have any questions please call me. Sincerely, Heather Ferris CIIS “Safety, health and independence for all Oregonians” 1 of 1 An Equal Opportunity Employer DHS 0198 (01/2023) HEALTH SYSTEMS DIVISION Provider Enrollment Unit Oregon Medicaid (Oregon Health Plan) What is this request for?– choose one See instructions on page 2 for required forms. New or re-enrollment Provider update – actively enrolled Revalidation-check box only if request is for a provider who received notice to revalidate or has been instructed to complete by Provider Enrollment Definitions and enrollment information – choose one Payable Individual Payable Individual – Individual provider who is enrolling to bill Oregon Medicaid directly (not through an organization) for services using their individual National Provider Identifier (NPI) . This includes Sole Proprietors who intend to use their Social Security Number (SSN) or their Federal Employer Identification Number (FEIN) and associated name for payment / tax purposes. Organization Organization – Groups, clinics, LLC, non-profit, etc. , who is enrolling to bill Oregon Medicaid for services rendered by individual providers using the organizations National Provider Identifier (NPI) . Business type – check all that apply (organizations only) Public providers are owned or operated by a State, county, city or other local governmental agency or instrumentality. Is the Provider owned or operated by a State, county, city or other local governmental agency or instrumentality? Yes No Corporation Government-owned Limited Liability Corporation (LLC) Limited Liability Partnership (LLP) Limited Partnership Not-for-profit Partnership Professional Corporation Other: (enter below) Provider Enrollment Information Payable Individuals and Organizations Page 1 of 7 OHA 3972 (0􀀖/2024) 200_520213 General information All Providers as defined in OAR 410-120-1260(3)(a) are required to enroll with Oregon Medicaid. OHA may deactivate providers who do not have any claim activity in an 18-month period. OHA recommends that you enroll if you have rendered services to an Oregon Medicaid Member in the last 12-months or plan to see a member within the next 30 days. Provider Enrollment reserves the right to make necessary changes to the information submitted such as provider type, specialty, and taxonomy. This action is necessary to correctly enroll the provider. Disclosure information Disclosure of Social Security Number is required pursuant to 41 USC 405(c)(2)(C)(i) to establish identification, 42 CFR 455.104 and 455.436 for exclusion verification and 26 CFR 301.6109-1 for the purpose of reporting tax information. OHA may report information to the Internal Revenue Service (IRS) and the Oregon Department of Revenue under the name, Soci

FAQs

Who needs to enroll with Oregon Medicaid under OAR 410-120-1260(3)(a)?

All providers as defined in OAR 410-120-1260(3)(a) are required to enroll with Oregon Medicaid.

How can a provider apply for an NPI?

Providers can apply through the NPPES website or call the NPI Enumerator to request a paper NPI application form.

What disclosure information is required in the enrollment process?

Disclosure of Social Security Number is required for identification and exclusion verification, and for reporting tax information to relevant agencies, including IRS and Oregon Department of Revenue.

Sep 19, 2026

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