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Kansas KanCare EPSDT Medical Necessity Form

Kansas uses this form, titled Non-Covered State Medicaid Plan Services Request Form for Recipients Under 21 Years Old, to request services the State Plan does not cover under EPSDT (KAN Be Healthy). The requesting clinician describes how they have treated the patient, health history, diagnoses and past treatment, and explains how the requested service will correct or ameliorate the condition.

Who completes it

A physician, licensed clinician or other provider completes the whole form, including requestor and provider names and NPIs, the requested procedure, product or service with its CPT or HCPCS code, and the 12 questions, then signs with credentials.

Submitting and payment

How to submit it
Send it with records that support medical necessity to the member's payer, using the prior authorization contacts printed at the top for KMAP fee-for-service, Healthy Blue, Sunflower and UnitedHealthcare.
Who pays
The form sets no fee; it asks the payer to authorize coverage of the requested service for the member.

Good to know

  • Questions 8 to 11 ask whether the request is experimental, whether it is safe and effective, and whether cheaper but similarly effective alternatives exist, with evidence if they do.
  • The definitions of safe and effective come from Kansas regulation 129-1-1, printed on the form: scientific evidence first, then professional standards of care, then expert opinion.
  • Question 7 needs a detailed discussion of how the service will improve or maintain health, compensate for a problem, prevent it from worsening or prevent further problems.
  • Not every field fits every request; the form asks for whatever will help the medical necessity decision. The current version is revised 09.2025.

Get the official form

Download the current version from the source each time; forms change without notice.

EPSDT Medical Necessity Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Where do you send the Kansas EPSDT medical necessity form?

To the payer responsible for the member. The top of the form lists prior authorization contacts for KMAP fee-for-service and for the KanCare plans Healthy Blue, Sunflower and UnitedHealthcare, so the provider uses the matching contact and attaches records that support medical necessity.

What does the Kansas EPSDT medical necessity form ask?

Twelve items: how long and in what capacity you have treated the member, health history, recent diagnoses, past and current treatment, how the requested service will correct or ameliorate the condition, whether it is experimental, safe and effective, cheaper alternatives, and the expected duration of treatment.

Can coverage be denied for lack of scientific evidence?

The regulation printed on the form says coverage of existing interventions shall not be denied solely because conclusive scientific evidence is absent. Without evidence, professional standards of care are considered, and if those are missing, outdated or contradictory, expert opinion is used.