Get Dmap 3108. Managed Care Plan/cco Provider Enrollment Request

The DMAP 3108 form is essential for Managed Care Plans and Coordinated Care Organizations (CCOs) to enroll their providers. This guide will walk you through each section of the form with clear instructions to ensure a smooth completion process.

Follow the steps to complete the DMAP 3108 form effectively.

1. Use the 'Get Form' button to access the DMAP 3108 form, ensuring that you can open and edit it as needed.
2. In the 'request information' section, fill in the name of the plan requesting enrollment, your contact name, phone number, and the name of the DMAP Encounter Data Liaison assigned to your plan. Ensure to include the effective date you are requesting for the enrollment.
3. Indicate whether the enrollment is for an individual provider or an organization by selecting the appropriate option.
4. For individual provider details, enter the provider's name, date of birth, and Social Security number. If enrolling as an organization, provide the business name, Federal Employer Identification Number (FEIN), and the organization type.
5. Complete the license/certification information section by providing the license number, effective date, licensing board, and expiration date, if applicable.
6. Include the National Provider Identifier (NPI) and any relevant taxonomy codes. Make sure to specify the primary code first, along with any secondary and additional descriptions.
7. Detail the provider type and service location by entering a physical street address. If applicable, include the mailing address and any additional information regarding Medicare and Medicaid provider IDs.
8. Answer the disclosure information questions, disclosing any adverse legal actions against the provider and providing information for entities with ownership interests.
9. Once all sections are completed, finish the form by connecting it with the EDMS Coversheet (DHS 3970). Include necessary requestor information and fax the completed forms as instructed.
10. Finally, save your changes, and consider downloading, printing, or sharing the completed DMAP 3108 form as necessary.

Begin filling out the DMAP 3108 form online to ensure a successful provider enrollment!