Skip to Main Content

Enroll in Our Network

Ambetter logo Wellcare logo

What type of contract

To enroll a new provider to your existing contract, please use the Existing Contract form.

To enroll as a Sunflower KanCare Medicaid provider, please go to the KMMS Provider Enrollment System to begin this process. From there, you can select which MCOs you would like to contract with.

Before you fill out the form below, please download all required documents and fill them out completely. Once you have completed your documents, be sure to finish the form below and upload your documents.

 

Which product line(s) are you interested in? required * Please select all the products you would like included in your agreement
What type of provider are you? required *

Contact Information

Who should we contact if we have questions about this contract request?

Correspondence Address

What is the mailing address we should use for contracting correspondence?

Group Practice or Facility/Agency Info

What type of facility is this? required *
Please do not use dashes ("-")
Does your Organization have multiple Facility/Agency NPIs on this application? required *
Complete and sign your W9 form and upload it here.
Complete and sign your Facility Credentialing Application and upload it here.
Complete and sign your Facility Roster and upload it here.
Complete and sign your CAQH Data Form and upload it here.
Complete and sign your Disclosure of Ownership Form and upload it here.

Provider Information

Please do not use dashes ("-")
Type of Provider required *
Complete and sign your W9 form and upload it here.
Complete and sign your CAQH Data Form and upload it here.
Complete and sign your Disclosure of Ownership Form and upload it here.

Practitioner Rights

Practitioners have the right to obtain the status of their application at any time throughout the credentialing process and the right to review information submitted to support the credentialing application. Practitioners also have the right to correct erroneous information, should any information obtained from other sources vary substantially from the information provided with the application. Should that occur, you will be notified by the Sunflower Health Credentialing Department and will have thirty (30) days to correct the information. To obtain credentialing status, or if you have questions about these rights, please contact the Sunflower Contracting Department by calling toll free 1-877-644-4623.