The professional authorizes payment including Medicaid/Medicare cross-overs from the Kentucky Medicaid Program for covered services specified by the criteria of the contract.
Billing: the professional personally shall not bill the Kentucky Medicaid Program for any service that is reimbursed as part of contractual agreement.
Overpayments: the Clinic/Corporation or Facility listed above shall be responsible for refunding any overpayments made for services rendered.
Dates: complete the Date Contract Effective in the Group Link Section, or the Date to be de-linked in the Group Delink Section, in MM/DD/YYYY format.
| Question | Answer |
|---|---|
| Form Name | Form MAP-347 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 18 |
| Avg. time to fill out | 3 min |
| Edition | 05/16 |
| Where to send | Kentucky Medicaid, P.O. Box 2110, Frankfort, KY 40602-2110 |
| Who signs | The individual provider, and an authorized official |
| Other names | MAP-347, MAP 347, MAP347, Statement of Authorization for Payment, KY Medicaid MAP 347 |
| Official source | Form MAP-347 (Rev 05/16), Kentucky Medicaid Program |
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