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How to become an Oregon Health Plan provider

National Provider Identifier (NPI) requirements

All health care providers subject to NPI requirements must provide DMAP their 10-digit NPI when enrolling as an Oregon Medicaid provider. (Providers not subject to NPI, such as transportation providers, are not required to provide an NPI.)
  • To get an NPI, apply online at the National Plan and Provider Enumeration System (NPPES) website.
  • To look up your NPI information, use the NPI Registry.

If you want to enroll with DMAP:

Try our online enrollment process. It provides links to additional forms you need to complete and submit.

Or, use the drop down box below to select the type of “Provider description” that matches you or the services you provide.

  • Complete and fax all forms and documentation listed for your description to DMAP under an EDMS Coversheet (MSC 3970). Requests submitted without the EDMS Coversheet will not be processed or returned to you.
  • If you are an out of state provider (more than 75 miles outside the Oregon border) seeking payment for services to OHP members, also include the claim you are seeking payment for.
  • If you do not bill us, but need to be reported in our system for other reasons (such as obtaining Provider Web Portal or Automated Voice Response access, or rendering/ ordering/ prescribing/ referring services for OHP members), select "Non-Payable Provider" from the drop down box below.

To learn more about enrolling with DMAP, please read our Provider Enrollment Handbook.


Provider Description
  
Required Forms
Required Documents
  
ABA Board-Certified Behavioral Analyst (BCBA)
33 (specialty 374)

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Background check, Copy of license, SSN documentation
ABA Board-Certified assistant Behavior Analyst (BCaBA)
33 (specialty 375)

DMAP 3113 (Word) (PDF)

Background check, SSN documentation
ABA Behavioral Analyst Interventionist (BAI)
33 (specialty 376)

DMAP 3113 (Word) (PDF)

Background check, SSN documentation
ABA BARB-Registered Licensed Health Care Professional
33 (specialty 377)

​DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)​

Background check, Copy of Board of Behavior Analysts (BARB) registration, Copy of license, SSN documentation
ABA Licensed Health Care Professional pending registration (Temporary enrollment through 12/31/15)
33 (specialty 378)

​DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)​

Background check, Copy of license, SSN documentation
Acupuncturist
02

​DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Ambulatory Surgical Center
05

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Personal Care Attendant
30

OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Fitness determination, I-9 form, SSN documentation
Audiologist
45

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavior Rehabilitation Services
(counties that provide local match funding)
06

​DMAP 3101 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Behavioral Health Adult Foster Home
33
OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)
Copy of AMH certification, IRS letter, SSN documentation
Behavioral Health Community Habilitation Employee
33 (specialty 448)

DMAP 3113 (Word) (PDF)​

SSN documentation
Behavioral Health Community Habilitation Program
33 (specialty 448)
DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)
Copy of AMH certification, IRS letter
Behavioral Health Licensed Residential Treatment Home or Facility
33

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Billing Provider (clinic/group billing)
09

DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Birthing Center
08

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Behavior Rehabilitation Services
(provides local match funding)
06

DMAP 3110 (Word) (PDF​), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)​

IRS letter
Chiropractor
16

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
LTC Nursing Services (formerly Contract RN)
86

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

 

Copy of license, DHS/APD authorization and contract number, SSN documentation
Copy Services
12

OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Dental Hygienist
18

DMAP 3102H (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Dentist
17

DMAP 3102D (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Denturist
20

DMAP 3102D (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Direct Entry Midwife
41

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Dispensing Optician (Individual)
44

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Durable Medical Equipment (DME)
36

DMAP 3116 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, Medicare information, Surety bond (unless exempted)
Emergency Response (Lifeline)
92

OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Family Planning Clinic
22

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Pharmacy license (if applicable)
Federally Qualified Health Center (FQHC)
15

DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

HRSA grant designation, IRS letter, Medicare cost report
Hearing Aid Dealer
23

OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Home Health Agency
24

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Medicare information
Hospice
27

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Medicare information
Hospital
26

DMAP 3111 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Medicare information
Independent Diagnostic Testing Facility
09

DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, Medicare information
Independent Laboratory
29

DMAP 3112 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

CLIA certification, IRS letter
Kidney Dialysis Center (Renal Disease Clinic)
32

DMAP 3109 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Licensed Clinical Social Worker
(only for billing exams/reports requested by DHS/OYA)
69

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
LTC Nursing Agency
88

DMAP ​3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

 

Copy of license, DHS/APD authorization and contract number, IRS letter
Behavioral Health LCSW
33
DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)
Copy of license, SSN documentation
Behavioral Health LFMT
33

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavioral Health LPC
33

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavioral Health Outpatient Program
(employs licensed staff exclusively)
33

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, List of licensed staff that includes credentials, Statement that facility will only employ licensed staff, Statement that facility will seek AMH certification before employing unlicensed staff
Behavioral Health Outpatient Program
(employs unlicensed staff)
33

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of AMH certification, IRS letter
Behavioral Health PMHNP
33

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavioral Health Psychiatrist
33

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavioral Health Psychologist
33

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Behavioral Health QMHP and QMHA
33

​​DMAP 3113 (Word) (PDF)

SSN documentation
Mobile Labs
09

DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Naturopath
38

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Non-Payable Provider
--

DMAP 3113 (Word) (PDF)

Nurse Practitioner (Advance Practice Nurse)
42

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Nursing Care Facility
81

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Medicare information
Occupational Therapist
45

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Optical Clinic
44

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Optometrist
43

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Oral Surgeon (Dental)
17

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Oral Surgeon (Medical)
34

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Oregon State Hospital
35

DMAP 3111 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Medicare information
Pharmacist
50

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Pharmacy
48

DMAP 3115 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Physical Therapist
45

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Physician Assistant
46

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Physicians
34

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Podiatrist
19

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Polygrapher
54

DMAP 3107 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Portable X-ray
52

DMAP 3105 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, Machine registration license, Medicare information
Psychologist
(only for billing exams/reports requested by DHS/OYA)
53

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Public Health Clinic
47

DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter, Pharmacy license (if applicable)
Registered Dietician
58

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Registered Nurse Anesthetist
37

OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
RN First Assistant
57

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Rural Health Clinic (RHC)
14

DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, Medicare information
School Medical
62

DMAP 3120 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Speech and Hearing Therapist
45

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Speech and Language Pathologist
45

DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, SSN documentation
Substance Use Disorder Counselors
03

DMAP 3113 (Word) (PDF)

SSN documentation
Substance Use Disorder Program
(employs licensed staff exclusively)
03

DMAP 3119 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter, List of licensed staff that includes credentials, Statement that facility will only employ licensed staff, Statement that facility will seek AMH certification before employing unlicensed staff
Substance Use Disorder Program
(employs unlicensed staff)
03

DMAP 3119 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of AMH certification, IRS letter
Targeted Case Management
64

DMAP 3103 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Transportation Air Ambulance
01

​DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Transportation Broker
01

​DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter
Transportation Ground Ambulance
01

​DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

Copy of license, IRS letter
Tribal Health Center (Indian Health Service or Tribal 638)
28

DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

IRS letter

If you want to enroll with an OHP health plan:

Medical and behavioral health providers: If you have questions about enrolling with a Coordinated Care Organization (CCO), contact the CCO. If you were denied participation in an OHP medical plan's provider network, read about the OHA Provider Discrimination Review process and form (Word) (PDF).

Dental providers: If you have questions about enrolling with an OHP dental plan, contact the plan.

Need help?

  • To check enrollment status: Try our online enrollment tracking.
  • To get help enrolling with DMAP: Call DMAP Provider Enrollment at 1-800-422-5047 or e-mail provider.enrollment@state.or.us.
  • To stay enrolled: Submit updates within 30 days of the change on either the Provider Web Portal Demographic Maintenance panel or DMAP 3035 form (Word) (PDF). Also send us a copy of your licensure renewal when you receive it from your licensing board. When faxing the DMAP 3035 or licensure renewals, please fax directly to Provider Enrollment at 503-947-1177 (Salem). An EDMS Coversheet is not required.
  • To request direct deposit: Submit the MSC 189 (Direct Deposit Authorization Form) to DHS/OHA Financial Services. For Medicaid EHR Incentive Program payments, enter the Oregon Medicaid provider number and account information associated with the payee you identified when registering with CMS for EHR incentive payments.

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