|** SPECIAL NOTICE **
This site is for newly enrolling MO HealthNet providers.
Effective July 1,2015,
institutional providers will
have to submit an application fee and may require
visit before being approved as a new provider. Individual
such as physicians, dentists, advanced
practice nurses and other individual
providers are not required to pay the application fee.
here for more information.
If you are already enrolled as a MO HealthNet provider and
need to make a change like adding a practice location or changing
your contact information, please complete a "Provider
Update Request" and fax it to (573) 634-3105. If you have any
questions submit them via e-mail to: firstname.lastname@example.org
If you are an existing MO HealthNet provider that is "Revalidating" your
enrollment because you received notice from MMAC, do not use this site.
Please submit your "Revalidation" application and supporting
documentation by e-mail to email@example.com, or by fax to
(573) 634-3105, or by mail to the address listed in your "Revalidation" package.
If you have questions, submit them via e-mail to firstname.lastname@example.org.
Click here for more information.
Please read instructions below before clicking Continue
Enrollment Information and Requirements for new applicants and existing
This Provider Enrollment Application site requires the
latest version of Internet Explorer or Mozilla Firefox. Paper applications are no longer available nor accepted
for the types of providers that can enroll on-line.
Instructions for each field of the MO HealthNet Enrollment Application
are listed on the bottom bar of the screen, click the HELP link at the bottom of
each part of the application for more detailed instructions. Click on the link
Provider Enrollment Information at the top of this page for program requirements
- The entire enrollment application must be completed on-line.
- A partial Enrollment Application may be saved and retrieved. However, all fields on the page must be
completed in order to utilize the "save" option for that page. A PIN is issued to retrieve the partial
application. The PIN cannot be used to retrieve an application that has been finalized and submitted.
- After finalizing an on-line application, ONLY the provider agreement "signature page" containing the
provider's original (wet) signature and any program requirement attachments must be faxed. All pages must be in an upright
position (not upside down or sideways).
- The signature page and attachments must be submitted on separate pages in the same transmission, or
the application will be denied. DO NOT SHRINK OR MINIMIZE PAGES to combine pages.
- Fax the signature page and required attachments in one transmission to 573-634-3105. Faxed pages
go directly to the Provider Enrollment database, not an actual fax machine. Only one signature page and
it's attachments are accepted per transmission.
- In order for the agreement and attachments to be submitted in one transmission, you must make sure that
each time a transmission is completed, the fax machine you are using not only finishes moving the pages through
the machine, but has also finished the transmission and has disconnected from the fax number dialed.
- Providers are required to print each page of their enrollment application and maintain for their records.
This includes the original (wet) signed provider agreement. However, ONLY the provider agreement
page and required attachments are required to be faxed.
- An altered agreement is automatically denied. Any enrollment form completed by typewriter or handwritten
is not acceptable. Fields cannot be blacked out, whited out, or crossed out;
writing information on the forms is not acceptable. The only writing permitted on the form is the
provider's original (wet) signature on the agreement page.
- If the application completed on-line needs changes, a new on-line application must be completed and
submitted. If additional information needs to be submitted, a letter may be sent with the signed
- Do not submit documentation that is not required for your provider type. Refer to the "Requirements for
Each Provider Type" section to determine required attachments.
- Fax number 573-634-3105 is used exclusively for on-line enrollment. All other faxes to
this number are disregarded without reply.
- Effective July 1, 2015, newly enrolling institutional providers will be
required to pay an application fee and may require a site visit before being
approved. Click here for more information.
- Applications for newly enrolling provider types requiring paper applications cannot be faxed; the original paper application must be sent
to Provider Enrollment by postal mail along with the required attachments.
All questions regarding provider applications and general questions for Provider Enrollment must be
communicated by e-mail to
A valid e-mail address is required on your application. The contact person's e-mail address also should be completed on the Enrollment
Application Part 2 along with the contact person's name. The contact person is notified of questions regarding the application.
If you have technical problems or problems faxing the
documents, contact the Help Desk at 573-635-3559. Instructions on how
to complete the application can be found by clicking the Help link at the
bottom of each part of the application.