Approved Provider Types for Teleservices

Provider Category

Provider Type

Cardiovascular Disease

19 – Physician (D.O.)
20 – Physician (M.D.)

ENT (Otolaryngology)

19 – Physician (D.O.)
20 – Physician (M.D.)

General Surgeon

19 – Physician (D.O.)
20 – Physician (M.D.)

Outpatient Mental Health Services

03 – County Indigent Health Care Program
10 – Physician Assistant/Nurse Practitioner/Clinical Nurse Specialist
16 – Licensed Professional Counselor (LPC)

18 – Licensed Clinical Social Worker (LCSW)
19 – Physician (D.O.)
20 – Physician (M.D.)

21 – Physician Group (D.O.s Only)

22 – Clinic/Group Practice

31 – Psychologist

46 – Federally Qualified Health Center (FQHC)

78 – Rural Health Clinic – Freestanding/Independent

79 – Rural Health Clinic – Hospital Based

97 – Psychology Group

OB/GYN

19 – Physician (D.O.)
20 – Physician (M.D.)

Ophthalmologist

19 – Physician (D.O.)
20 – Physician (M.D.)

Orthopedist

19 – Physician (D.O.)
20 – Physician (M.D.)

Prenatal (Medicaid and CHIP Prenatal)

10 – Physician Assistant/Nurse Practitioner/Clinical Nurse Specialist

19 – Physician (D.O.)
20 – Physician (M.D.)

33 – Registered Nurse/Nurse Midwife

46 – Federally Qualified Health Center (FQHC)

78 – Rural Health Clinic – Freestanding/Independent

79 – Rural Health Clinic – Hospital Based

Primary Care Provider

03 – County Indigent Health Care Program

10 – Physician Assistant/Nurse Practitioner/Clinical Nurse Specialist

19 – Physician (D.O.)
20 – Physician (M.D.)

22 – Clinic/Group Practice

46 – Federally Qualified Health Center (FQHC)

78 – Rural Health Clinic – Freestanding/Independent

79 – Rural Health Clinic – Hospital Based

Psychiatrist

19 – Physician (D.O.)
20 – Physician (M.D.)

Therapies – OT PT ST

34 – Physical Therapist

35 – Occupational Therapist

50 – CCP Provider

Urologist

19 – Physician (D.O.)
20 – Physician (M.D.)