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Network Participation Request Form: Ancillary

PLEASE NOTE: This is not a guarantee of Contract. The information you provide is used by Wellcare of KY to evaluate the offering of a Contract and is not representative of an application or a Legal Agreement. Requests are processed in the order they are received. Reviews will be performed within one (1) business week. A member of our team will contact you to relay if a decision is made to move forward with the contracting process within your region.

If you are not contracted with Wellcare of KY, complete the Network Participation Request Form below.

Ancillary

Back to primary service type selections

Please select Provider type required * ASC Dialysis DME FQHC Home Health Hospice Independent Laboratory/Pathology and/or Radiology RHC Transportation

Error: Provider Type is required.

Please populate the below.

Provider Name *

Error: Provider Name is required.

Provider Type *

Error: Provider Type is required.

NPI *

Error: NPI is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: License Number is required.

Line of Business (Please select all that apply) required * Medicaid Medicare Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: Provider Name is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Directory Inclusion choice is required.

Pay To Address

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: Pay To State is required.

Zip Code *

Error: Pay To Zip Code is required.

Your Contact Information

Primary Contact Name *

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Email *

Error: Primary Contact Email is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Email *

Error: Credentialing Contact Email is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information *

Error: Credentialing Contact Phone Number is required.

Please attach the documents listed below. * Attachments required for submission

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)
LOAP/Practitioner Roster Form (XLS)
CVO Credentialing Form - Facility (PDF)
Provider Erollment Letter advising of specific details of the enrollment request. (On your company letterhead)

Disclosure of Ownership Form

Items in the trash will be permanently removed after 30 days.

W-9 Form

Items in the trash will be permanently removed after 30 days.

Copy of Current Malpractice Certificate of Insurance

Items in the trash will be permanently removed after 30 days.

CVO Credentialing Form - Facility

Items in the trash will be permanently removed after 30 days.

Provider Enrollment Letter advising of specific details of the enrollment request. (On your company letterhead)

Items in the trash will be permanently removed after 30 days.

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