Skip to Main Content

Non-Contracted Provider Set-Up

The preferred and quickest method for enrolling a non-contracted provider or practitioner is via a claim submission.  

Please submit your claim and we will complete enrollment based on the NPI, TIN and program of the submitted claim, which will be processed in approximately 21 days.

If you would like to proceed with submitting a non-contracted enrollment request, you may do so by clicking the button below.  Please note enrollments processed via request may take up to 60 days to process. If sending a claim, please do not also submit a request.

Please attach a completed W9. Please submit enrollments through your Provider Relations staff member if you bill with a SSN as your TIN.

Is this an update or a new submission? *

Practitioner Name

Practitioner Gender *

Billing Address

Service Location Address

Last Updated: 03/15/2021