Kansas > Statewide > Medical Assistance Program
Kansas Medical Assistance Program (KMAP) Provider Application - Kansas
| Kansas Medical Assistance Program (KMAP) Provider Application Form. This is a Kansas form and can be used in Medical Assistance Program Statewide . |
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SUPPLIER APPLICATION CHECKLIST Below is a checklist for your convenience to ensure all forms are completed in their entirety. If any of the following items are not complete, do not contain original signatures, or are not dated, or if required items are not included, your entire application will be returned. Please sign the application in BLUE ink. This helps minimize the confusion as to whether signatures are original. Copies of signed forms and/or stamped signatures are not acceptable. Unless otherwise noted, all requirements apply to individual applicants as well as group applicants. Kansas Medical Assistance Program (KMAP) provider application Original signature and date are required. If a question is not applicable, please mark the field N/A. Specialty Listing: A specialty must be marked. Disclosure of Ownership and Control Interest Statement Name, phone number and address must be filled in. All questions or boxes must be completed or checked. Original signature and date are required. KMAP Provider Agreement All four boxes on the first page must be completed. Original signature and date must be on page 5 of 5. Note: If the effective date requested is prior to the signature date of the provider agreement, a claim showing services were rendered on or before the requested effective date must be attached. Current license An expired license will not be accepted. The license must be from the state in which the provider will be practicing. W-9 A copy of the W-9 is required. Durable Medical Equipment Supplier Attestation Form If you are enrolling as a durable medical equipment (DME) supplier, you must attach this form. Original signature and date are required. Rev. 05/2010 American LegalNet, Inc. www.FormsWorkFlow.com Dear prospective provider: Thank you for your interest in the Kansas Medical Assistance Program (KMAP). The application materials listed below must be completed and returned to the fiscal agent so your enrollment can be processed. Submission of incomplete application materials will delay your enrollment. · · · · · KMAP Application Specialty Listing The Ownership and Control Interest Disclosure Statement KMAP Provider Agreement A copy of your current license (if required) In order to facilitate the assignment of a provider number, please complete and submit the application materials with ORIGINAL SIGNATURES. Please retain copies of your application materials for your records. You will receive written notification upon approval or denial of your enrollment. All claims must be received by the current fiscal agent within one year from the date of service. Claims not received in a timely manner (within one year from the date of service) will not be considered for reimbursement except for claims submitted to Medicare, claims determined to be payable by reason of appeal or court decision, or as a result of agency error. Regulations regarding payment of services to out-of-state providers (more than 50 miles from the Kansas border) allow payment consideration for out-of-state services provided to KMAP beneficiaries if one of the following situations exist: · · An out-of-state provider may be reimbursed for covered services required on an emergency basis. An emergency is defined as those services provided after the sudden onset of a medical condition manifested by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. In these situations, please contact the KMAP Prior Authorization department to receive authorization prior to services being rendered. Failure to contact the Prior Authorization department may result in denial of your claim. An out-of-state provider may be reimbursed for nonemergency services if the Prior Authorization department, on behalf of the Kansas Health Policy Authority, determines that the services are medically necessary. Failure to meet either of the above situations may result in denial of your claim. · · If either situation presently exists or may exist, then please complete the enclosed application forms and be sure that all information requested is provided. If you have questions concerning enrollment, please contact Provider Enrollment at P.O. Box 3571, Topeka, Kansas 66601 or by telephone at 785- 274-5914, between 8:00 a.m. and 4:30 p.m., Monday through Friday. If you have any questions regarding prior authorization, please call 1-800-285-4978. Sincerely, KMAP Provider Enrollment American LegalNet, Inc. www.FormsWorkFlow.com Choose One: New Enrollment Re-enrollment Kansas Medical Assistance Program (KMAP) PROVIDER APPLICATION This application must be completed in its entirety. Do not leave any questions blank. If a question is not applicable, indicate so with an N/A in the appropriate field. Incomplete applications will result in a delay in the processing of your application. Section A BUSINESS NAME OR PROVIDER NAME: OR PROVIDER: First Middle Last PROVIDER'S SOCIAL SECURITY NUMBER: PROVIDER'S TAX IDENTIFICATION NUMBER: PROVIDER'S LICENSE/CERTIFICATION NUMBER: LICENSE/CERTIFICATION EFFECTIVE AND EXPIRATION DATES: FROM TO PROVIDER'S NPI: DEA NUMBER: TAXONOMY CODE: A copy of the letter or e-mail received from NPPES assigning the NPI is required. GROUP NUMBER: If a group number is not indicated, the provider will not be listed as a member of the group. GROUP NPI: GROUP TAXONOMY CODE: WAS THE PREVIOUS PROVIDER ENROLLED IN THE KANSAS MEDICAL ASSISTANCE PROGRAM? YES NO PREVIOUS KMAP PROVIDER NAME AND NUMBER: DATE SERVICES WILL FIRST BE PROVIDED TO KMAP BENEFICIARIES: KHPA approved 03/21/2011 American LegalNet, Inc. www.FormsWorkFlow.com TYPE OF PRACTICE ORGANIZATION: INDIVIDUAL PRACTICE CHARITABLE HOSPITAL-BASED PHYSICIAN PARTNERSHIP PRIVATELY OWNED OTHER CORPORATION LLC MUNICIPAL OR STATE-OWNED PROVIDER'S PHYSICAL LOCATION (This is the practice or physical site location.) ADDRESS CITY PHONE NUMBER E-MAIL ADDRESS STATE EXT COUNTY FAX NUMBER ZIP CODE (nine digits) PROVIDER'S MAIL TO ADDRESS (This is the address to which correspondence will be mailed.) ADDRESS CITY PHONE NUMBER E-MAIL ADDRESS PROVIDER'S PAY TO ADDRESS (This is the address to which payments will be mailed.) PAYEE NAME ADDRESS CITY PHONE NUMBER E-MAIL ADDRESS PROVIDER'S HOME OFFICE ADDRESS (This is the address of business home office.) ADDRESS CITY PHONE NUMBER
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