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Kansas KMAP General Prior Authorization Request

The Kansas Medical Assistance Program uses the General Prior Authorization Request for fee-for-service services and items that have no service-specific PA form. Providers meet it when a KMAP fee-for-service beneficiary needs approval for a procedure, equipment, prosthesis or vision service. Up to eight service lines carry the procedure code, dates, units and charge, and a consultant marks each line approved or denied.

Who completes it

The requesting provider completes every field outside the office-use areas, including the 10-digit KMAP provider number, the beneficiary's 11-digit Medicaid ID, the diagnosis, service lines and a detailed explanation of medical necessity, then signs and dates it. The fiscal agent and the Kansas Department for Children and Families complete the office-use sections.

Submitting and payment

How to submit it
Fax the completed form to the KMAP prior authorization fax printed on it, or mail it to the Office of the Fiscal Agent as the instructions direct. The form must be completed in its entirety.
Who pays
PA does not guarantee eligibility, and if the service is not covered by Medicaid or MediKan, the authorization is void.

Good to know

  • Approval does not override PCCM referral limitations or other program limitations, so those rules still apply after a PA is granted.
  • Vision requests also need the date of the last examination and the previous prescription, distance and add, for each eye.
  • Each detail line needs a procedure code, from and through dates, a description of the service or item, units requested and the total amount to be charged.
  • The form is for KMAP fee-for-service only. Most Kansas Medicaid members are in KanCare managed care plans, which run their own prior authorization processes.

Get the official form

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

General Prior Authorization Request

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

Does the KMAP General PA form work for KanCare members?

No. It is a Kansas Medical Assistance Program fee-for-service form. Most Kansas Medicaid members are enrolled in KanCare managed care organizations, and those plans run their own prior authorization processes, so check the member's enrollment before using the KMAP form.

Where are the instructions for the Kansas General Prior Authorization Request?

Two instruction pages follow the form in the same PDF, revised 10.2017. They mark nearly every field as required, explain the eight detail lines and the vision-only fields, and say to leave the For Office Use Only section to the fiscal agent and the Kansas Department for Children and Families.