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    ePREP Provider Agreement and Application Addenda

    ​Provider Agreement

    All Maryland Medicaid providers must sign the Provider Agreement in ePREP at enrollment and revalidation​. View a copy of the Maryland Medical Assistance Provider Agreement​.

    Application Addenda

    Certain provider types and programs must complete and submit an addendum with their provider application. 

    Use the links in the table below to access your addendum. Complete your addendum and upload it to ePREP > Applications tab >Additional Information > Practice Information. Be sure to upload any other documents requested in the addendum. 

    View a full list of all provider types here​.

    Addendum by Provider/Program​
    PT Code
    ADAA Certified Addictions Outpatient Program​​
    50
    Ambulance Company
    T1
    Ambulatory Surgical Center
    39
    Autism Waiver
    40
    Brain Injury Waiver
    86
    Centering Pregnancy Individual 
    Centering Pregnancy Group​​
    N/A
    Clinic, Drug​
    32
    Clinic, Federally Qualified Health Center​
    34
    Clinic, General
    38
    Clinic, Local Health Department
    35
    Community Options, Assisted Living (ALF)
    Community Options, Other
    76
    ​Community Violence Prevention
    ​VP
    DDA Services, Provider New Enrollees
    90
    Dental Pro​vider Individual​
    Dental Provider Group​
    14
    Diabetes Prevention Program (DPP) Provider
    DP
    Diagnosis Services, Other
    60
    Dialysis Facility
    61
    DMS/DME Provider​
    62
    Doula Individual​
    Doula Group
    DL
    EPSDT Therapeutic Behavioral Services
    51
    Freestanding Oncology Services
    36
    ​​Gender Affirming Treatment - Electrologists and Medical Tattoo Artists
    HCBS, 1915i
    89
    HCBS, 1915i Individual
    HCBS, 1915i Group
    HG
    Healthy Steps Individual​
    Health Steps Group​
    ​NA
    HIV Case Management
    VC
    ​​HM​O/PACE​
    70​
    Home Health Agency
    41
    Home Visiting Services
    HV
    Hospital, Acute
    01
    Hospital, Acute Rehabilitation
    03
    Hospital, Chronic
    05
    Hospital, Chronic Rehabilitation
    04
    Hospital, Specific Other Acute
    06
    Hospital, Specific Other Chronic
    07
    IMD Residential SUD Adult
    54
    Intermediate Care Facility, Addiction
    55
    Local Education Agencies/Local Lead Agency
    91
    Medical Day Care, Adults
    42
    Medicare Crossover Only​​
    XV
    Mental Health Case Management Provider
    CM
    Mental Health Clinic
    MC
    Mobile Treatment Program​
    MT
    Nursing Facility​​
    57
    Ordering, Referring, Prescribing (ORP-only) Provider​
    ​92
    Pain Management
    N/A
    Partial Hospitalization Program
    MH
    Pediatric Nursing/Home Health Aide Services Agency
    53
    Portable X-Ray
    59
    Psychiatric Rehab Services Facility
    PR
    Residential Treatment Center
    88
    School Based Health Center (SBHC)
    N/A
    Suppo​rted Employment
    SE
    Urgent Care Center​
    08​



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