KanCare Vendor Intake Form

This form is intended for Medicaid providers, professional associations, manufacturers or advocacy organizations to submit requests to the Medicaid program to consider new services or products to Medicaid coverage. Coverage decisions are based on legal requirements, cost, clinical soundness, efficacy and safety. Requests should be accompanied with research and evidence to support the request. Each request will be reviewed by the Medicaid clinical team and requestors will be notified of our decision.
Introduction Letter Upload
Have you submitted a request for the same coverage in the past year?

Is the FDA or governing body's approval complete, provisional, pending or investigational?

If the potential standard of care or course of treatment is currently under FDA or other governing body approval, provide the current industry guidelines that support its position in testing or a treatment algorithm, if available.
Provide literature about the value that added or expanded coverage creates.
Provide literature supporting efficacy and safety and any significant clinical trials with associated impact on outcomes.
Is the recommended testing or treatment modality more cost effective than currently covered alternatives?

Provide supporting documentation on projected cost.