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  • Enrollment And Disenrollment Form - Kmap

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ENROLLMENT and DISENROLLMENT FORM (Complete top sections for enrollments and bottom section for disenrollments.) Enrollments 1. To Change Plans Coventry Health Care of Kansas, Inc. Unicare HealthConnect.

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How to fill out the ENROLLMENT And DISENROLLMENT FORM - KMAP online

Filling out the Enrollment and Disenrollment Form for KMAP can seem complex, but this guide will provide you with clear, step-by-step instructions to make the process easier. Whether you are enrolling in a health plan or disenrolling from one, this comprehensive overview will support you in completing the form accurately online.

Follow the steps to complete the form online:

  1. Click 'Get Form' button to obtain the form and open it in the editor.
  2. Begin with the top section if you are enrolling. Indicate your choice of health plan by marking the box next to one of the options: Coventry Health Care of Kansas, Inc., Unicare, or HealthConnect (only if applicable).
  3. If changing Primary Providers for beneficiaries in HealthConnect, complete the section by providing the Primary Provider's name, Medicaid number, and phone number. Also, fill in the beneficiary’s name, Medicaid ID number, and telephone number.
  4. Print the name of the beneficiary or casehead and ensure that the required signatures are provided: the beneficiary/casehead and the provider, along with the date.
  5. If you are disenrolling a beneficiary, navigate to the bottom section of the form. Provide the provider's name, Medicaid number, phone number, and the beneficiary’s details the same way as in enrollment.
  6. Select a reason for disenrollment from the provided options, ensuring it is appropriately marked. If necessary, include an explanation in the space provided.
  7. Obtain the provider's signature for the disenrollment request and add the date.
  8. After reviewing all entered information for accuracy, save your changes, and you may download, print, or share the completed form as required.

Complete your enrollment or disenrollment form online to ensure timely processing and access to health benefits.

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KMAP must receive claims or tracer claims within 12 months of the date the service was provided (KSA 39-708a). Inpatient hospital services must be received within 12 months of: 1) the date of discharge; or 2) the last date of service on an interim bill.

Our electronic payer id is 68069. If you are having issues with electronic billing, please call our EDI department at 800-225-2573 extension 25525 or e-mail at EDIBA@centene.com. 3. Submit claims through KMAP.

Payor ID: 47163 Office Hours: Monday - Friday 7:00 a.m. - 4:30 p.m.

The Kansas Medical Assistance Program (KMAP) provides secure web sites for our member, provider and drug labeler communities. In order to access the secure web site, users must register for a user ID and password.

If in doubt, contact KMAP Customer Service at 1-800-766-9012 (members) or 1-800-933-6593 (providers). KanCare Health Plans. General KMAP program information can be accessed from the menu links above.

Payer ID: 96385 Click here for more info! Note: Pre-Enrollment is required for Electronic Remittance Advice.

Mail premium to: KanCare Premium Billing P.O. Box 842195 Dallas, TX 75284-2195 • Call 1-866-923-2724 for a self-service payment. Make an online payment. Families who do not pay their monthly premium are at risk of losing CHIP coverage for their child(ren).

Medicaid in the State of Kansas KanCare is the program through which the State of Kansas administers Medicaid.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232