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Provider Forms and References

Appointment of Representative Form
Behavioral Health Psychiatric Residential Treatment Facilities PRTF Prior Authorization Request Form
Entity / Group Provider Disclosure of Ownership and Control Interest Online Form
External Independent Third Party Review Provider Bulletin
Community Plan of Kansas KanCare External Independent Third Party Review Request Form
Kansas Provider Appeal Form
Kansas Provider Appeal Processes
Kansas Provider Grievance Online Form
Kansas Provider Referral Online Form
OptumRx Commercial and Medicaid Payer Sheet - This document provides information on electronic claims processing, specific to NCPDP defined fields and requirements, for OptumRx Commercial and Medicaid business.
OptumRx UnitedHealthcare Community Plan of Kansas (Dual Eligible Only) Payer Sheet - This document outlines the processing instructions for OptumRx UHC Plan of Kansas (Dual Eligible Only) business.
Community Plan Kansas KanCare Primary Care Physician PCP Locked In Referral Form
Synagis Enrollment Form

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Prior Authorization / Pre-Certification Forms

Visit the Prior Authorization Page

Provider Portals

The following links will bring you to each provider portal.

KanCare - Medicaid for Kansas
Kansas Department of Aging and Disability Services (KDADS)
Kansas Department of Health and Environment (KDHE) / Division of Health Care Finance (DHCF)
Kansas Medical Assistance Program (KMAP)
MARCH Vision Care
Logisticare - Kansas transportation providers
SkyGen - SkyGen Dental, Vestica Healthcare and Ocular Benefits

Submit a Pre-Service Appeal and or Grievance for a Medicaid Member

Medicaid Pre-Service Appeal or Grievance