Read MAP-811 Application Form Revised - Provider Alert - Passport Health Plan text version

Subject: MAP-811 Application Form Revised

From: Sent: To: Passport Health Plan May 24, 2011 All Passport Health Plan Providers

Provider Types Affected:

All Passport Health Plan Providers

Background:

Effective 6/1/11, KyHealth Choices will only accept the 7/1/2010 versions of the MAP-811 Individual, MAP811 Non-Credentialed, and Annual Disclosure of Ownership (ADO) for provider credentialing. KyHealth Choices will not accept any prior versions of these forms if they are received for the first time on 6/1/11 or after. However, if an application was originally submitted and received prior to 6/1/11, and subsequent submissions of that same application are submitted after 6/1/11, those applications may be accepted on the old forms.

Provider Action Needed:

Please use the links below to access and use the most recent versions of the MAP-811 Individual, NonCredentialed, and ADO applications. MAP-811 Individual Application (Revised 07/01/2010):

www.chfs.ky.gov/NR/rdonlyres/CE69C244-0CAE-4EEF-8574-2CE48F71A180/0/MAP811CredasofNov2010.pdf

MAP-811 Non-Credentialed (Revised 07/01/2010):

www.chfs.ky.gov/NR/rdonlyres/39E2A5BD-4567-4204-AC58-08DEB1F258D6/0/Map811NonCredentialedasof Nov2010web.pdf

ADO ­ Annual Disclosure of Ownership (Revised 07/2010):

http://chfs.ky.gov/NR/rdonlyres/A6F049D9-E128-4CBD-83B5-14B7372E32C1/0/ADO.pdf

Questions:

If you have any questions about your enrollment, please call KyHealth Choices toll free at (877)-838-5085. A provider enrollment specialist will be available to help you between the hours of 8 a.m. and 4:30 p.m. EST, Monday through Friday.

©2011 Passport Health Plan PS-11120

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MAP-811 Application Form Revised - Provider Alert - Passport Health Plan

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MAP-811 Application Form Revised - Provider Alert - Passport Health Plan