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 | 06/20/25 |
| 301 | Qualified Mental Health Associate (QMHA) | 06/20/25 |
| 302 | Qualified Behavioral Aide (QBA) | 06/20/25 |
| 308 | Day Treatment Model, Specialty 308 | 06/20/25 |
Return to Enrollment Checklists page.
If you have any questions, please contact the Gainwell Technologies Contact Center at (877) 638-3472 from 8:00AM to 5:00PM, Monday through Friday.