MAP-811Checklist
NOTICE: Pursuant to 907 KAR 1:672 Section 2 1(c) (1), you must be enrolled as a participating provider prior to being eligible to receive reimbursement. Enrollment in the program is not a guarantee; therefore, providing services to
Kentucky Medicaid members prior to your effective date is at your own financial risk.
A complete list of enrollment requirements for each provider type can be found on our website at the following link: https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx
Did you:
Complete all questions? Questions not applicable should be completed with “N/A”.
(Applications will be rejected for any questions left blank.)
Sign and date signature page (page 12) Electronic or stamped signatures are not accepted.
Attach appropriate licenses and/or certifications and all other required documents for requested effective date as well as current?
Attach verification documentation for NPI and Taxonomy Code(s) from CMS NPI vendor or NPPES.
Attach a MAP-347 if individual wants to be linked to group KY Medicaid provider number.
Attach a copy of your Social Security card if you are enrolling as an individual. Attach your IRS verification letter if you are applying with a FEIN.
If you are subject to an application fee, please attach a check payable to the KY State Treasurer. For more information on the application fee, please refer to your Provider Type Summary at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx.
Keep a copy of the application for your records.
Not completing these reminders will delay the processing of your application. Please ensure that all reminders above are completed. Other information not mentioned above may be requested during the processing of your application.
If you are completing this application for ENROLLMENT and you will not be participating with a MCO, please send this application to the following address:
Kentucky Medicaid
P.O. Box 2110
Frankfort, KY 40602
Providers may submit the Medicaid enrollment packet (MAP-811 and all required documentation) to one MCO for processing simultaneous with that MCO’s contract and credentialing application process, in lieu of sending it directly to Medicaid.
Please do not send the application directly to the Department for Medicaid Services. This will delay the processing of your application.
If you have any questions regarding your enrollment, please call Kentucky Medicaid toll free at (877) 838-5085. A provider enrollment specialist will be available to help you between the hours of 8 am and 4:30 pm, EST, Monday through Friday.
MAP-811 Provider Application Instructions
Section A: Administrative Information
Enrollment Block:
•If applying for a Kentucky Medicaid number for the first time, check first block.
•If reapplying as a Kentucky Medicaid number, check second block and enter your provider number in question #1.
•If a change in ownership has occurred, check third block.
•If applicant has been excluded from Medicare/Medicaid by Federal, State, or court sanction and has been terminated as a result, please declare “I am enrolling as a reinstatement” by checking fourth block.
MCO Participation: If you will be participating with a KY Managed Care Organization (MCO), please indicate.
Field # Description
1If a Kentucky Medicaid provider number has already been assigned to this provider, enter provider number.
2Please mark the appropriate box. Indicate name of individual provider or if an entity/group is enrolling, please input entity/group name. For individual applicants, the name referenced in this field, must match all supporting documentation. Please include all suffixes in name if applicable. For entity/group applicants, the name referenced in this field and/or in question #3 must match all supporting documentation.
3Enter the name the provider will be doing business as, if different than question #2. Otherwise, you may enter N/A. If you are applying for an individual provider number, do not enter your employer’s name in this field. Enter the provider/Owner Email
4Please mark the appropriate block.
5Please mark the appropriate block.
6Enter License/Certificate number for the applicant. Attach a copy of your license.
7Enter provider type. (EXAMPLE: physician; dentist; etc.) A complete listing of provider types can be found at https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspx.
8Enter the type of service that will be provided. (EXAMPLE: Acute care; diabetic supplies; etc.); Telehealth response
required: Yes/No.
9Enter the date you wish your enrollment with Medicaid to be effective. Date must be in mm/dd/yyyy format.
10Enter your National Provider Identifier (NPI). Include verification email or National Plan and Provider Enumeration System (NPPES) printout.
11Enter your Taxonomy Code(s) associated with your NPI. (Attach extra sheet if necessary.) Include your email verification or NPPES printout.
12Enter individual Social Security Number (SSN).
13Enter FEIN only if you own the FEIN 100%.
14Enter date of birth of applicant provider.
15Please indicate which number will be used for reporting monies to you from Medicaid for 1099 purposes. Example: If you are an individual provider completing this question, please input your SSN or a FEIN if you own the FEIN 100%. If you are applying as an individual and want your monies to go to the entity/group, the individual must complete a MAP- 347 form in order to be linked to the group setting under which they are reporting.
16Please mark the appropriate box for tax structure.
17Enter the first and last name of the person to sign for a summons in case of a lawsuit (N/A is not acceptable).
18Enter telephone number of person named in question #17.
19Enter Physical address, physical county phone, fax,
20Enter Mailing address and credentialing contact information. The field must be completed with an email address.
21Enter Pay-to/1099 address.
22If you have held any Kentucky Medicaid group/facility numbers in the past three years, please enter on form. If not, please indicate with N/A.
23Please list all Medicare numbers of applicant.
24Please complete bed breakdown of facility.
25Enter the Administrator’s name with telephone and fax number.
26Enter the Assistant Administrator’s name, telephone number, and fax number.
27Enter the Controller’s name, telephone number, and fax number.
28Enter the Accountant or CPA’s name, telephone number, and fax number.
29Enter the Fiscal Year End (FYE).
30Complete if you wish to link to a group. Attach a MAP-347 for any additional group you wish to link to.
Section B: Disclosure of Ownership and Control Interest
1If there has been a change of ownership, list previous Medicaid provider number(s) and start and end dates for each.
2Describe relationship or similarities between the provider disclosing information on this form and items “A” through “C”.
3Do you plan to have a change in ownership, management company or control within the next year? If so, when?
4Do you anticipate filing bankruptcy? If so, when?
5Enter the Federal Tax Identification Number (if there is an affiliation with a chain) along with name, address, city, state and zip code.
6List name, address, SSN/FEIN of each person or organization having direct or indirect ownership or control interest in the disclosing entity. Complete question #7 with the officers’ and board members’ information. If no one owns 5% or more of provider, check box and complete question #7 with the officers’ and board members’ information. If you are applying as an individual and do not own a FEIN, please enter your name and information. In addition, all business locations of the corporate entity must be disclosed.
Indirect Ownership Interest - means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Ownership interest - means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Person with an ownership or control interest - means a person or corporation that:
•Has an ownership interest totaling 5% or more in a disclosing entity;
•Has an indirect ownership interest equal to 5% or more in a disclosing entity;
•Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;
•Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity;
•Is an officer or director of a disclosing entity that is organized as a corporation; or,
•Is a partner in a disclosing entity that is organized as a partnership
List officers’ and board members’ information of disclosing entity. A social security number of officer or board member may be required.
Subcontractor- means an individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients, OR an individual, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or lease of real property) to obtain space, supplies, equipment or services provided under the Medicaid agreement
If applicant is related to persons listed in questions #6, #7, and #17, list the relationship.
List name of managing company, if not applicable enter N/A. A FEIN may be required.
List names of the disclosing entities in which persons have ownership of other disclosing entities.
Other Disclosing Entity- means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Act. This includes:
•Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (Title XVIII).
•Any Medicare intermediary or carrier.
•Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX or the Act.
11If entity engages with subcontractors (such as physical therapist, pharmacies, etc.,) which exceeds the lesser of $25,000 or 5% of applicant’s operating expense, list subcontractor’s name and address.
Significant Business Transaction- means any business transaction or series of transactions that, during any one fiscal year, exceeds the lesser of $25,000 or 5% of applicant’s operating expense.
Reserved for Future Use.
List name, SSN, address of any immediate family member who is authorized to prescribe drugs, medicine, devices or equipment.
List the name of any individuals or organizations having direct or indirect ownership or controlling interest of 5% or more who have been convicted of a criminal offense related to the involvement of such persons or organizations in any problem established under Title 19 (Medicaid) or Title 20 (Social Services Block Grants) of the Social Security Act (SSA) or any criminal offense in this state or any other state since the inception of those programs. Please also indicate any KY Medicaid provider number(s) associated with individual or organization.
List any agent and/or managing employee who has been convicted of a criminal offense related to any program established under Title XVIII, XIX or XX of the SSA or any criminal offense in this state or any other state since the inception of those programs. Indicate any KY Medicaid provider number(s) associated with individual or organization.
Agent- means any person who has been delegated the authority to obligate or act on behalf of a provider.
Managing Employee- means a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency.
List the name, title, SSN, and business address of all managing employees as defined in 42 CFR 455.101.
List name, address and SSN/FEIN of each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5% or more.
MAP-811 (Enrollment) (Rev. 03 2019)
COMMONWEALTH OF KENTUCKY
DEPARTMENT FOR MEDICAID SERVICES
SECTION A: ADMINISTRATIVE INFORMATION
For Kentucky Medicaid Use Only
ATN#_____________________
Identifier: __________________
Provider Type _____________
Reviewer’s Initials: ____________
I am enrolling as a: |
New Provider |
Re-applicant |
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Change of Ownership |
Reinstatement |
Will you be contracting with a KY Managed Care organization (MCO)? Yes |
No If yes, please indicate which MCO? |
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Aetna Better Health of KY |
Anthem |
Humana CareSource |
Passport Health Plan |
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WellCare of Kentucky |
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Kentucky Medicaid Provider Number: |
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Check here for N/A |
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(Complete only if you have indicated Reapplicant, or Reinstatement above.) |
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2. |
Applying As: Please check only one box and print clearly. For individual applicants, |
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Teaching Facility (PT 01 or 02) |
please input any suffixes if applicable. |
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Yes |
No |
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Individual |
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Entity |
Group |
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Last: |
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First: |
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MI: |
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Name: |
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3. |
Doing Business As (DBA): |
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Provider/Owner Email: |
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4. |
Please select: |
Public |
Private |
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5. Please select: |
Profit |
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Non-Profit |
6. |
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License/Certification #: |
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7. Provider Type: |
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8. |
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Type of Service: |
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9. Date Provider Requests Effective Enrollment: ____/____/_____ |
Provide Telehealth Services? |
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No |
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(Date must be in mm/dd/yyyy format.) |
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10. |
National Provider Identifier (NPI): |
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11. Primary Taxonomy Code: (Attach extra sheet if necessary. Must match |
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NEPPS) |
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SSN: |
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13. FEIN (Please list |
only if you own the FEIN 100%): |
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14. Date of Birth: |
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15. |
DMS will report all monies paid to the IRS. Please indicate which number you use for tax reporting. (If you are |
enrolling as an individual and do not own a FEIN, please check SSN field). (Check one only.) |
SSN |
FEIN |
16. |
Tax Structure: Please select only one structure. |
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Individual |
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Partnership |
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Corporation |
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Government/Non-Profit |
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Sole Proprietor |
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Estate/Trust |
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Public Service Corporation |
Limited Liability Company |
17. |
Agent of Service in Case of Summons (N/A not acceptable). |
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18. Telephone # of Agent of Service |
First Name: |
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Last Name: |
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(N/A not acceptable). |
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PRIMARY PHYSICAL BUSINESS LOCATION: |
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(If you have more than one physical location, attach a copy of items listing additional locations. If an entity/group is applying, each additional location may require separate enrollment.)
Street Address:
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City: |
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State: |
Zip: |
Phone #: |
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MAILING ADDRESS: |
(Check here if same as primary physical business address) |
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Address: |
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City: |
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State: |
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Zip: |
Credentialing Contact Information (Required) |
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(This individual will be contacted should any information be needed to process the application.) |
Note: Your email address will |
not be given to any outside party for any reason. DMS may use provider email addresses to send provider letters/notices. |
Name: |
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Email Address: |
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Phone: |
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Fax Number: |
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21. |
PAY-TO/1099 ADDRESS: |
(Check here if same as primary physical business address) |
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Address : |
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City: |
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State: |
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Zip: |
Contact First Name: |
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Contact Last Name: |
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Phone #: |
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22. |
List any Kentucky Medicaid group/facility numbers you have held in the past three years. |
Check here for N/A |
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23. |
Please list all Medicare Provider Numbers. (Attach extra sheet if necessary.) Check here for N/A |
Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please
print or type. Reformatted or altered applications will not be accepted. |
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MAP-811 (Enrollment) (Rev. 03 2019)
24. Bed Breakdown Check here for N/A |
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_________ Acute |
_________ TCU |
_________ Hosp. Swing |
_________ ICF/IID |
_________ ICU |
_________ Nursery |
_________ Rehab. Hosp. |
_________ Ventilator Unit |
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Surgical ICU |
_________ Neonatal ICU |
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Psych. Hosp. |
_________ Brain Injury |
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Burn ICU |
_________ CCU |
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PRTF |
Unit |
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_________ NF/Medicaid |
_________ NF (Medicare/Medicaid) |
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_________ Other /specify: |
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25. |
Administrator: |
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Phone: |
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Fax: |
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Check here for N/A |
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26. |
Assistant Administrator: |
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Phone: |
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Fax: |
Check here for N/A |
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27. |
Controller: |
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Phone: |
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Fax: |
Check here |
for N/A |
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28. |
Accountant or CPA: |
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Phone: |
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Fax: |
Check here for N/A |
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29. |
Fiscal Year End Date (FYE): |
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Check here for N/A |
30.If you are applying as an individual, please complete if you wish to link to a Clinic Corporation or Facility. 
Check here for N/A
I hereby declare that I
(Individual Provider Enrolling)
have entered into a contractual agreement with the following:
(Clinic/Corporation or Facility Name) |
(KY Medicaid Provider Number of Clinic/Corporation or Facility) |
to provide professional services. I authorize payment including Medicaid/Medicare cross-overs, from the Kentucky Medicaid Program for covered services provided by me and specified by the criteria of our contract. I understand that I, personally shall not bill the Kentucky Medicaid Program for any service that is reimbursed as part of contractual agreement, and further that Clinic/Corporation or Facility Name listed above shall be responsible for refunding any overpayments made for services rendered. (Please note: If you choose to link to more than one group please attach a MAP-347).
Fill out all Applicable Sections. Write Not Applicable (N/A) for questions that do not apply. Applications will be rejected for any questions left blank. Please
print or type. Reformatted or altered applications will not be accepted. |
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