WellCare of Kentucky Medicaid members have gotten phone calls from scammers posing as WellCare. These scammers claim that members owe money.

WellCare of Kentucky will never contact you to ask for payment. Do not pay them.

Please let your bank or credit card company know if you paid someone pretending to be your Medicaid plan. Be sure to also report this issue to your local law enforcement agency.

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Add a Facility Request Form

Behavioral Health Facility

Instructions for adding a facility to an existing contract.

Back to primary service type selections

Please select Provider type required * BHSO - Behavioral Health Service Organization BHMSG - Behavioral Health Multi-Specialty Group CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center CCBHC - Certified Community Behavioral Health Clinic PRTF - Psychiatric Residential Treatment Facility Residential Crisis Stabilization Unit

Error: Provider Type is required.

Is the facility ASAM Certified? required * Yes No

Error: Group Provider is required.

Please populate the below.

Provider Name *

Error: Provider Name is required.

NPI *

Error: NPI is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: Provider Name is required.

Line of Business (Please select all that apply) required * Medicaid Medicare Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Facility/Group Service Address Information.

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Are Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Directory Inclusion choice is required.

Do you offer Telemedicine Services? required * Yes No

Error: Telemedicine Services information is required.

Do you participate with KHIE (Kentucky Health Information Exchange)? required * Yes No

Error: KHIE information is required.

Correspondence Address

Contract Entity Name *

Error: Contract Entity Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Pay To Information

Pay To Name *

Error: Pay To Name is required.

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: State is required.

Zip Code *

Error: Pay To Zip Code is required.

Your Contact Information

Primary Contact Name *

Error: Primary Contact Name is required.

Email *

Error: Primary Contact Email is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Email *

Error: Credentialing Contact Email is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information

Please attach the documents listed below. *Attachments required for submission.

ASAM Certification (BHSO - ASAM Certified)
Disclosure of Ownership Form^*
W-9 Form^*
LOAP/Practitioner Roster Form (XLS)
Copy of current Malpractice Certificate of Insurance^*
CVO Credentialing Form - Facility: Facility: BHSO, CDTC, CMHC, CCBHC, PRTF, Residential Crisis Stabilization Unit (PDF)^*
Provider Erollment Letter - advising of specific details of the enrollment request. (On your company letterhead)^*
Facility Licensure^*
CLIA Certificate(Required if Lab Services performed at location)