Beneficiary Information

 • Beneficiary Insurance Premium Payment Assistance

 • Beneficiary TPL Insurance Information Update

 • Notice of Facility Admission/Discharge (MS-2126)

 • Request for Medicaid Hearing (Beneficiary)

Claim Attachments

 • Certificate of Medical Necessity

 • Hard Copy Attachment Cover Sheet

 • Individual Adjustment Request

 • Medical Attestation

 • Medicare Nonassigned Request

 • Multiple Adjustment Request

 • NDC Detail Attachment

 • TPL CARC & RARC

Claims (Sample Forms and Instructions)

 • 1500 Claim Form

 • ADA Dental Claim Form

 • Pharmacy Claim

 • UB-04

Commercial Nonemergency Transportation

 • Certification by Medical Provider for Transportation Services

 • Commercial NEMT Medical Necessity

 • NEMT Transportation

Consent

 • Abortion Necessity

 • Consent For Sterilization - HMS 687

 • Consent For Sterilization - HMS 687-1 Spanish

 • Consent for Sterilization Form Instructions

 • Hysterectomy Necessity

Dental

 • Orthodontic Certification

Developmental Scales (Birth to 4 Years)

 • Developmental Scales (Birth to 4 Years)

DME

 • DME Invoice Pricing Supplemental Form

 • Enteral Nutrition Prior Authorization Request

 • Home Monitor Informational Form

 • Home Oxygen Informational Form

 • Manual Wheelchair Prior Authorization Request

 • Negative Pressure Wound Therapy Prior Authorization Request

 • Negative Pressure Wound Therapy Renewal Prior Authorization Request

 • Physician Order Form/Medical Necessity for Diabetes Testing Supplies

 • Power Wheelchair Prior Authorization Request

 • Pulse Oximeter Request

 • Special Wheelchair Seating Device Prior Authorization Request

 • Total Parenteral Nutrition Prior Authorization Request

Doula

 • Doula Attestation Form Packet

 • Doula Services Referral Form

Drug Manufacturer

 • Kansas Drug Rebate Web Portal Application

Electronic Health Record

 • Request to apply for EHR Incentive Programs

HCBS

 • HCBS TBI Kansas Traumatic Brain Injury Rehabilitation Facility Referral

 • HCBS TBI Program Eligibility Attestation

 • HCBS/FE Adult Day Care Log

 • HCBS/FE Assistive Technology Receipt

 • HCBS/FE Comprehensive Support and Personal Care Services Log

 • HCBS/FE Comprehensive Support Log

 • HCBS/FE Enhanced Care Services Log

 • HCBS/FE Nursing Evaluation Visit

 • HCBS/FE Personal Care Services and Enhanced Care Services Log

 • HCBS/FE Personal Care Services Log

 • HCBS/FE Personal Care Services Log (Facility)

 • HCBS/FE Personal Care Services Weekly Care Log

 • HCBS/FE Wellness Monitoring

Home Health Agency

 • Acute Care Home Health Service Plan Request

 • Change In Home Health Service Plan Or Discharge From Services

 • Diabetes Management Home Health Service Plan Request

 • Long-Term Care Home Health Service Plan Request

 • Primary Care Quality Measures For Medicaid Home Health Beneficiaries

Hospice

 • Hospice Drug Statement

KBH - EPSDT

 • KDHE Requisition for Laboratory Specimen Kits and Supplies

KBH-EPSDT

 • Blood Lead Screening Questionnaire

 • Developmental Scales (Birth to 4 Years)

 • EPSDT Medical Necessity Form

 • Hearing Health History (5 Years and Up)

 • KBH-EPSDT Screening

 • Risk Indicators for Hearing Loss Checklist (Birth to 4 Years)

Lock-In Referral

 • Lock-In Beneficiary Referral

Pharmacy

 • Drug Shortage Request Form

 • Kansas Fee-for-Service Drug Shortage Log

 • NDC Pricing Inquiries

 • Request for Review - NDC-HCPCS or CPT Crosswalks

Prior Authorization

 • Bone Anchored Hearing Aids

 • Explanation of Necessity for Hearing Aids

 • General Prior Authorization Request

 • Hyperbaric Oxygen Therapy Prior Authorization

 • Hyperbaric Oxygen Therapy Prior Authorization - Renewal

 • Psychiatric Residential Treatment Facilities PA

Provider Information

 • Attestation of Compliance with Section 6032 of the Federal Deficit Reduction Act

 • Behavioral Interventions Attestation

 • Collaborating Clinician Statement

 • Disclosure of Ownership and Control Interest Statement

 • Driver Attestation

 • EDI - Electronic Claims Submission Application

 • EDI Update Form

 • HCBS Supplemental Form

 • KANCARE PBM Combined Pharmacy Credentialing Form

 • Kansas Organizational Provider Credentialing/Recredentialing Application

 • National Provider Identifier Update

 • NEMT Provider Application

 • NPI Information as Applicable Form

 • Provider Agreement

 • Provider Insurance Premium Payment Assistance

 • Provider TPL Insurance Information Update

 • Provider Update

 • Request for Medicaid Hearing (Provider)

 • Screening, Brief Intervention, and Referral to Treatment Facility Attestation

 • Section 12 Attestation / Consent and Release Form

 • TPL Premium Provider

WORK

 • WORK Allocation Instrument