MCO Contracting Request Form

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Instructions

This form is for currently enrolled Kansas Medical Assistance Program (KMAP) providers who are interested in contracting with a Managed Care Organization (MCO).

You must complete one form for each service location address. Once we have verified your information, we will generate an enrollment application pre-populated with information currently on file. You will receive two emails. One that includes the Application Tracking Number (ATN) associated with your request. The second email will include the password necessary to access the application. When you receive the second email, return to the enrollment portal and resume the application. Review the information, complete any information required for your provider type and specialty, attach required documentation and submit the application. We will forward it to the MCO(s) you have selected below. The MCO is responsible for all communication with you once your application has been forwarded.

Complete the required information below. All items marked with an asterisk (*) indicate a required field.

Provider Information

Enrollment Type

Entity Type

Last Name

First Name

Middle Name

Suffix

Legal Name

NPI

SSN

EIN

Provider ID

Provider Group ID

MCO Selection

Participating MCO Programs

Select MCO Program(s). At least one selection is required.

Requestor Information

Last Name

First Name

Middle Name

Address Line 1

Address Line 2

City

State

Country

ZIP Code/ Postal Code

Phone Type

Telephone Number

Telephone Number Extension

Fax Number

Email Address

Confirm Email

Submit Confirmation

Congratulations! You have successfully submitted your MCO Request Form for the following program(s):

Upon submission, you will receive two emails. The first will contain the below tracking number. The second email will include the password and instruction for completing the MCO enrollment process.

Tracking Number

Click on the link below to download and print the MCO Contracting Request Form

MCO Contracting Request Form

Coversheet

Sincerely,

State Medical Assistance Program

appshcproduct@gainwelltechnologies.com