Provider Web Portal Quick Guide - Disenrollment

Last update: 01/08/2024

Table of Contents



Select Disenroll from the Provider Web Portal home page. It can be found on the left-hand sidebar under the "Provider" category.

Screenshot showing disenrollment link

Click "Disenroll Provider".

disenroll provider link

Indicate the reason for disenrollment using the drop-down menu. A comment may be added but is not required. Select a future disenrollment date between a minimum of 30 days and a maximum of 90 days. Fill out provider contact name, phone and email.

Disenrollment options include: Change of Ownership, Closing the Business, Leaving the Health Care Field, Moving Out of State, Retiring, and Other.

Providers disenrolling for Change of Ownership may select a disenrollment date in the following range: from the first of the current calendar year (a retroactive date) and up to 90 days from the current date (in the future). Providers with this disenrollment reason must attach a completed Change of Ownership form ('Attachment Type' will be Change of Ownership); otherwise, the disenrollment request will not process successfully.

disenrollment reasons screenshot

A disenrollment request tracking number will be created.

disenrollment tracking number

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Verify Disenroll Status

Select Disenroll from the Provider Web Portal home page. It can be found on the left-hand sidebar under the "Provider" category.

provider web portal home page

Select 'Disenroll Status'.

select disenroll status

Enter the disenrollment tracking number. Click Search. Results will appear in the panel below.

enter disenrollment tracking number and view results

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Cancel Disenrollment

Providers may cancel a disenrollment request using the "Cancel Disenrollment" button. Once the button is removed, the cancellation option is no longer available.

To cancel the disenrollment, follow the steps in the Verify Disenroll Status section. The Cancel Disenrollment button will appear after results are displayed in the Disenroll Summary panel. Click yes to proceed with canceling disenrollment.

cancelling disenrollment

After clicking yes, the following panel will display.

disenrollment summary screen

If a provider verifies the disenrollment status again, using the previous disenrollment tracking number, they will see the updated status of Denied.

disenrollment status summary 2

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Need More Help?

Visit the Quick Guides web page to find all the Provider Web Portal Quick Guides.