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Get Passport Health Plan Registration Non Participating Providers Form
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How to fill out the Passport Health Plan Registration Non Participating Providers Form online
This guide provides clear and concise instructions on how to complete the Passport Health Plan Registration Non Participating Providers Form online. Follow the detailed steps to ensure accurate completion of all necessary fields.
Follow the steps to successfully complete the form online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Section A, provide your contact information, including your name, date, phone number, fax, and email address. Ensure the details are accurate for effective communication.
- Move to Section B, where you will input your practice information. Fill in your last name, first name, middle initial, title or degree, specialty, NPI number, taxonomy code, group or facility name, physical address, city, state, zip code, county, phone number, fax, social security number, and Kentucky Medicaid number, which is necessary for payment processing.
- Continue to input the billing information in Section C. Provide your Tax Identification Number, tax name, billing contact name, billing contact phone number, billing address, city, state, zip code, and county.
- After filling in all the sections, be sure to fax the completed form along with a W-9 to Provider Maintenance at (484) 496-7685 or email it to the provided support email address.
- Once your form is received, a provider ID number will be assigned, which will be returned to you via fax. Please note that claims will not be processed without an active Kentucky Medicaid number.
- If you have any questions, contact Provider Services at (800) 578-0775. To apply for a Kentucky Medicaid number, you may visit the appropriate link provided.
- Lastly, it is advisable to review the Plan’s Member Rights and Responsibilities along with provider communications, which can be accessed online.
Complete your forms online efficiently and accurately.
Yes, Passport is a Medicaid managed care organization in Kentucky. It provides various health services to eligible residents. If you're looking for information on the Passport Health Plan Registration Non Participating Providers Form, you can discover how Passport Medicaid can support your health care needs.
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