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Change Age Restrictions

KanCare Provider Enrollment and Changes: Providers must use the Kansas Modular Medicaid System (KMMS) Provider Enrollment Wizard to update their information for any or all of the Medicaid fee-for-service (FFS) and managed-care organization (MCOs) health plans.

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Ambetter or Medicare Change Age Restrictions

Please use the form below to change your practice's age restrictions for Ambetter or Medicare members.

Change Status for: * Ambetter (Health Insurance Marketplace) Medicare (Wellcare by Allwell / Wellcare Complete)

Provider NPI *

Provider Name

First Name *

Last Name *

Tax ID # *

Group/Facility Name *

Group NPI # *

Service Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Provider Type * Primary Care Physician (PCP) Specialist

New Ambetter Age Restrictions

New Wellcare Age Restrictions

Comments

Update Requested By:

First Name *

Last Name *

Contact Email *

Contact Phone *