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
MCO Selection

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

Requestor Information
Submit Confirmation

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

Please reference the tracking number below for all inquiries related to this application.


Tracking Number

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

MCO Contracting Request Form

Coversheet

 

Sincerely,

Kansas Medical Assistance Program

Kansas-Provider-Enrollment@dxc.com

Contact us: 1 -800-933-6593

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