Provider Forms and References
- 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 Lock-In Beneficiary Referral Form
- Kansas Provider Appeal Form
- 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.
- Synagis Enrollment Form
Prior Authorization / Pre-Certification Forms
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