Application Information

Thank you for your interest in becoming a KY Medicaid Provider. To learn more about applying, please click on one of the links listed below.

• What is a KY Medicaid Provider?
• How do I enroll as a Medicaid Provider?
• How long will the enrollment process take?

Enrollment in the program is not a guarantee; therefore, providing services to Kentucky Medicaid members prior to your effective date is at your own financial risk.

The Department for Medicaid Services (DMS) only contracts with providers or entities qualified under 907 KAR 1:671 and 907 KAR 1:672 and approved by DMS to participate. DMS reserves the right to approve or reject a contract with any prospective provider.

Notice: Pursuant to 907 KAR 1:672 Section 2 1(c)(1), you must be enrolled as a participating provider prior to being eligible to receive reimbursement.

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Beginning on November 1, 2011, there are processes to enroll and submit your forms to KY Medicaid or their MCO's.

If you are not assigned to an MCO or choose not to participate in a MCO, (fee for service provider), and to become a Kentucky Medicaid provider, you must complete and submit the appropriate MAP 811 form and supporting documentation. The MAP 811 is the Medicaid Provider application; two versions of this application are available to providers, one for non-credentialed providers and one for credentialed individuals. The type of provider you are enrolling as will determine which application you complete and submit for processing. To verify which forms you need, refer to Provider Type Summaries and Forms.

Once you completed and signed your forms, send them to:

Kentucky Medicaid
Provider Enrollment
P.O. Box 2110
Frankfort, KY 40602

If you would like to request participation in a MCO, please refer to one or all of the MCO websites listed below:

• If you would like to request participation as a Passport provider, submit completed, signed forms to: 5100 Commerce Crossings Drive; Louisville, Kentucky 40229 or call 1-800-578-0775. Note: If you are requesting participation as a Passport MCNA provider, please contact Sophia Wallen at (877) 375-6262 extension 103 to obtain a dental credentialing packet.
• If you would like to request participation as a Coventry Cares Provider, visit their website or call 1-855-300-5528
• If you would like to request participation as a KY Spirit Health Plan provider, visit their website or call 1-866-443-3153.
• If you would like to request participation as a Wellcare of Kentucky Provider, visit their website or call 1-877-339-9457.

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The enrollment process can take up to 90 days to complete, assuming all the necessary forms and information/verification are submitted. If there are any outstanding accounts receivable, you will need to satisfy those debts before the application can be approved.

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