Rendering/Servicing Providers

Rendering Providers must enroll AFTER their employer has registered in IMPACT: 

Types of Employers:

1. Individual Sole Proprietor
2. Provider Group
3. Companies providing the following Developmental Disabilities Medicaid Waiver Services:

How Do I Enroll as a Rendering/Servicing Provider?

1. An Individual- Type 1 National Plan Identifier (NPI) is required to enroll.  If you do not have an NPI, please apply for one on the National Plan and Provider Enumeration website.
2. Obtain a Single Sign-On account to access the IMPACT provider enrollment system. Please use the Single Sign on (pdf)(PDF) PowerPoint Presentation for assistance with completing this step. If you need assistance with creating the account or logging into the system, please contact the IMPACT Login helpdesk at 1-888-618-8078 or via email at IMPACT.Login@Illinois.gov.
3. Go to "New Enrollment." The next screen will have a list of Enrollment Types. Do not change the Enrollment type. Click the "Submit" button at the bottom of the screen. The default option (Individual/Sole Proprietor; Regular Individual Sole/Proprietor) is the correct enrollment type for Behavior Service providers, Nurses, Counselors/Therapists, Occupational Therapists, Physical Therapists and Speech Therapists.
4. Step 1: Basic Information: Keep applicant type as "Rendering/Servicing Only." Enter the applicant's personal information including the applicant's home address. Do NOT enter a work address. Click on the "Finish" button when complete. A pop-up screen will open with an Application ID, please write down this number for your records. If you are unable to finish the application you may return to the application later by going to "Track Application" and entering the assigned Application ID.
5. Step 2: Add Specialty: Please see the attached DDD Provider Mapping Spreadsheet for the correct Provider type, Specialty and Sub-specialty. Click the "Add" button to enter the correct specialty. Do NOT enter an End Date. Click the "OK" button when you have entered the provider type, specialty, and subspecialty. Click the "Add" button again if you need to add additional specialties. After entering the correct specialties, you will need to click on the "Primary Specialty" button and select a primary specialty. You do not need to enter a Start Date or End Date.
6. Step 3: Associate Billing provider: This step requires that you add both DDD and the agency or entity that you are working for as a billing provider. DO NOT ENTER YOUR OWN NPI NUMBER on this step. You will need to enter the NPI number or the IMPACT ID number of the agency/entity.
   1. Click the "Add" button. Select from the drop-down box either the NPI or Provider ID based on the information provided by the billing provider. Do not enter a Start Date or End Date. Click the "Confirm" button. The Billing Provider's Name should populate with the Agency or Individual's Name that is the applicant's employer. Click "OK" if the information is correct.
   2.  Click the "Add" button a second time to add DDD as a billing provider. Select Provider ID button and enter the ID number 70946388. Do not enter a Start Date or End Date. Click the "Confirm" button and DDD Billing Provider should populate as the Provider's Name. Click "OK" if the information is correct.
7. Step 4: Add License/Certification/Other: This step is N/A for level 2 behavior therapist and should be skipped. All other applicants will need to add their license/certification information by clicking the "Add" button, selecting the correct License/Certification Type, entering the License/Certificate number and the Effective Date and End Date. Click the "Confirm License/Certification/Other" button and then the "OK" button. If the applicant has more than one license or certification, please click the "Add" button again and add the additional information.
8. Step 5: Add Provider Controlling Interest/Ownership Details: This step only needs to be completed if the applicant has ownership or controlling interest in a Medicaid or Medicare funded entity. If you have questions about this step including the information that is required to be disclosed, please contact the IMPACT Helpdesk at (877) 782-5565.
9. Step 6: Add Taxonomy Details: Click the "Add" button, enter the taxonomy code and click on the "confirm taxonomy." Check the Description to ensure that it is correct, and then click "OK." The Taxonomy Code enter must be the taxonomy code associated with the applicant's NPI. Please do NOT enter the taxonomy code for the employer's NPI. If you are unsure of the taxonomy code, please complete a search of the applicant's NPI number on the NPPES NPI Registry and enter the taxonomy code(s) listed on the registry. Enter the Start Date. You may use the Enumeration Date as listed on the NPI Registry as the Start Date.
10. Step 7: Associate MCO Plan: Click the "Add" button and enter the DDD MCO plan ID number: 3000006. Do not enter an Associate Start Date or End Date. Click the "Confirm/Search Plan" button and the Plan Name and Program Code Description will populate with the DDD MCO plan name and program code description. Click "OK."
11. Step 8: Enrollment Checklist: Please read the questions and answer each of them with a "No" or "Yes." When completed click the "Save" and the "Close" button at the top of the screen.
12. Step 9: Submit Enrollment Application for Approval: Click the "Next" button. The next screen is the IMPACT Terms and Conditions which is the Medicaid agreement between the applicant, DHS DDD and the IL Department of Healthcare and Family Services. If you do not have time to read the entire IMPACT Terms and Conditions, please click the "print" button on the blue ribbon on the upper right hand side of screen and review the agreement at a later time. If the employer or another person other than the applicant is completing the application, the employer must have a signed paper copy of the IMPACT Terms and Conditions (Medicaid Agreement) in the applicant's employee file. After reviewing the IMPACT T & C, please click the box next to the "By checking this, I certify that I have read and that I agree and accept all the enrollment terms and conditions in herein that are applicable to me." Then click the "Submit Application" button at the top of the screen.
13. After submitting the application, please email the application ID to DHS.DDDMedProv@illinois.gov for review.
14. Complete a Payee Designation/Authorization Form (IL462-1180).  This document should be maintained on record by the billing provider.