KY Medicaid Provider Enrollment August 23,

Provider Services Branch Contact Information Toll-Free Phone number: (877) Hours of Operation: 10:00 am-4:30 pm DMS Provider Services Branch Website: 2

The Enrollment Process Determine enrollment requirements at the following: Obtain Application and Additional forms at the following : The provider completes and submits the appropriate forms with all supporting documentation to the following address: KY Medicaid P.O. Box 2110 Frankfort, KY For assistance in completing the forms, you can refer to the instructions sheets included with each form or contact the Provider Services Branch at (877)

Troubleshooting Forms Please complete all questions on the form. Questions not applicable should be completed with “N/A”. Attach appropriate licenses and/or certifications and all other required documents for requested effective date as well as current. Attach a copy of the Social Security card for individual Keep a copy of the application for your records. 4

Troubleshooting Forms Continued.. If the provider is enrolled in CAQH (Council for Affordable Quality Healthcare), the CAQH application can be submitted in lieu of the KAPER-1 form. Information regarding CAQH can be found at CAQH tutorials can also be found on their website. 5

Maintenance of Provider File After the individual provider is enrolled, certain changes may occur. In order to keep their provider number current, the appropriate form or documentation must be submitted. Some of the most common changes/updates are the following: - License Renewals - Change of Address- Map-529 form - Change of Name- A signed written request from individual provider requesting name change in addition to a new license and social security card reflecting the new name must be submitted. - Linkage to group- Map-347 form 6

Questions? 7