Kansas Health Homes Member Assignment Refusal Form Directions

Kansas Health Homes
Member Assignment Refusal Form
Directions: Please complete sections 1 through 3 and send via fax, email, or standard mail to:
Amerigroup
Sunflower State Health Plan
United Health Care
9225 Indian Creek Pkwy, Ste. 400
8325 Lenexa Dr.
9900 W. 109th St. #200
Overland Park, KS 66210
Lenexa, KS 66214
Overland Park, KS 66210
Member Services: 1-800-600-4441
Member Services: 1-877-644-4623 Member Services: 1-877-542-9238
Fax: 1-877-820-9028
Fax: 1-888-453-4316
Fax: 1-855-252-9324
Current MCO assignment: Amerigroup
Medicaid ID#:
Section 1: Member Information
Date of refusal:
Name of member:
Date of Birth:
Address:
Phone:
Email:
Section 2: Health Home Partner Information
Name of health home partner:
Name/Position or Title of Individual submitting the refusal:
Address:
Phone:
Email:
Section 3: Reason Member Assignment is Refused
The member has been previously discharged by the HHP with applicable notice in writing provided
The member resides outside the geographic range served by the HHP, e.g. a Community Mental Health
Center
The member is outside the age range parameters established by the HHP, e.g. a pediatrician is not
required to serve adults
The HHP has reached its capacity to provide HH services
The HHP is a Tribal 638/Indian Health Facility and wished to limit its HH activities to Native Americans
The HHP is a provider of services to people with intellectual or developmental disabilities (I/DD) and
wished to limit its HH activities to those with I/DD
Other:
TO BE COMPLETED BY MCO
Date refusal received:
Corresponding follow up letters:
MCO Representative name:
Member Change of Health Home Letter
Title:
HHP Notification of Enrollment Letter (Alternate
Phone number:
HHP)
Name of alternate HHP:
HHP Disenrollment Letter (First HHP)
HHP Contact Name:
Health Home Member Disenrollment Letter
HHP accepts referral:
Yes
No
Health Home Not Available Letter
HHP start date:
Date response letters mailed:

Download Report