Kansas - Application Request | Providers – Amerigroup
ks-appRequest.css
ProviderApplicationRequest_new.css
contactModal.js
Providers

Provider Application Request

Thanks for your interest!

Step 1: Obtain a Kansas Medicaid ID

You must have an active Kansas Medicaid ID to complete the credentialing process. Don’t have one? Visit the KMAP website and complete the
provider enrollment application.

Step 2:

For Professional Practitioners

We only accept credentialing of new professional applicants through the Council for Affordable Quality Healthcare

If you have a valid Kansas Medicaid ID:
Visit CAQH and use your current CAQH ID to grant Amerigroup access to your credentialing file; then complete our online application request, the attached Kansas Disclosure of Ownership and Controlling Interest Form, and a current W9.

If you do not currently participate in CAQH:
Complete our online application request. We will then nominate you in the CAQH database, allowing you access to the database in order to complete the application.

We cannot initiate credentialing unless all information is current in CAQH. Your application for credentialing does not guarantee network participation. You cannot begin to see Amerigroup members until you receive notification of your effective date for participation with Amerigroup Kansas, indicated by both an executed contract and completed credentialing.

If you are new to the Amerigroup network, you will require both credentialing and a contract. Please complete each of the forms below and return them to:

fax: 1-866-494-5632
email: ks1credentialing@amerigroup.com

Joining an Existing Amerigroup Contracted Provider Group?
We only require your CAQH number to credential and add a professional provider to an already contracted entity.

For Facility, Ancillary and HCBS Providers

We accept the State of Kansas Facility Joint MCO Application for all Facility, Ancillary and HCBS providers.

If you are new to the Amerigroup network, you will require both credentialing and a contract. Please complete each of the forms below and return them to:

fax: 1-866-494-5632
email: ks1credentialing@amerigroup.com

Please complete the Updated Roster September 2016.

Call the Amerigroup Kansas Provider Relations team at 877.434.7579 if you have questions.

Kansas
Provider Application Request
Provider Application Request
Mailing Address has been validated via USPS and auto-corrected. Please review Mailing Address, City, State, Zip Code for accuracy and then click SUBMIT to continue.
Completion of this application request form indicates your interest only. You will be contacted by a Provider Relations Representative regarding next steps.
Note: Completion of this form is not part of the credentialing application for the network participation.
Fields marked with an * must be completed.
FirstName
LastName
PrimarySpecialty
GroupName
MailingAddress
City
State
ZipCode
County
OfficePhone
Fax
EmailAddress
ContactPerson
NPI
CAQH
Market