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Network Participation Request Form: Behavioral Health Facility

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.

Behavioral Health Facility

Back to primary service type selections

Please select Provider type required * BHSO - Behavioral Health Service Organization ASAM Certified BHMSG - Behavioral Health Multi-Specialty Group CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center CCBHC - Certified Community Behavioral Health Clinic PRTF - Psychiatric Residential Treatment Facility Residential Crisis Stabilization Unit

Error: Provider Type is required.

Please populate the below.

Provider Name *

Error: Provider Name is required.

Provider Type *

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CAHD ID # *

Error: CAHD ID is required.

NPI *

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Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: Provider Name 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 *

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Street Address *

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City *

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State *

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Zip Code *

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County *

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Phone Number *

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Fax Number *

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CLIA Number *

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CLIA Expiration *

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Include in Provider Directory required * Yes No

Error: Provider Inclusion choice is required.

Pay To Address

Street Address *

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City *

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State *

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Zip Code *

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Your Contact Information

Primary Contact Name *

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Email *

Error: Provider Name is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

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Email *

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Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information

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

ASAM Certification (BHSO- ASAM Certified)
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 *

Error: Disclosure of Ownership Form upload is required.

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

W-9 Form *

Error: W-9 Form upload is required.

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

Copy of Current Malpractice Certificate of Insurance *

Error: Copy of Current Malpractice Certificate of Insurance upload is required.

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

CVO Credentialing Form - Facility *

Error: CVO Credentialing Form upload is required.

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) *

Error: Provider Enrollment Letter upload is required.

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

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