Manuals, Forms and Resources

Authorizations, Claims & Payment

• 837 EDI Companion Guide - Now included in the Provider Office Manual.
• CARC/RARC Crosswalk (PDF) - Claims EX (Explanation) codes from the remittance advice to the CARC (Claims Adjustment Reason Codes) and RARC (Remittance Advice Remark Codes) on the Healthcare Claim Payment/Advice (835). These and other lists can also be found on the X12 website.
• Coordination of Benefits Entry Walk-Through Guide (PDF)
• Corrected Claims Quick Reference Guide (QRG)
• DRG Reviews Presentation (PDF) - from Oct. 2, 2018, webinar
• Member ID Card Reference Sheet (PDF) - Examples of Sunflower member ID cards for Medicaid, Medicare and Marketplace
• KAN Be Healthy (KBH) and Early and Periodic Screening, Diagnostic, Treatment (EPSDT) Billing and Coding Tips (PDF)
• New Century Health - For members 21 years of age or older, authorizations for oncology agents listed on the KDHE Prior Authorization Criteria for Oncology Agents and Auxiliary Treatment Agents require review by New Century Health.
• Medical Necessity Criteria

Quality of Care

• Provider Quick Reference Guide (QRG) (PDF)
• Appointment Availability and Wait Times
• Adult Provider Visit Guide (PDF)
• Chasing the Chart (PDF) Information about medical records requests.
• HEDIS Guides and FAQs
  
• KAN Be Healthy (KBH) and Early and Periodic Screening, Diagnostic, Treatment (EPSDT) Guide
  
• KDHE Smoking Cessation (PDF) - HUD housing is now smoke-free. Tips to help members quit tobacco.
  
• Mental and Physical Health (PDF) - Member-facing information about whole-person health
  
• Preventive and Clinical Practice Guidelines
  
• Quality Care Pointers for Providers (PDF) (PDF reference resource)
• Pregnancy Quick Reference Guide for Providers
• Telehealth Best Practices - From HHS

HCBS & Behavioral Health

• Consumer Access Guide to HCBS Services in Kansas – From KDADS Community Services and Programs Commission
  
• In-Home Assessments
  
• Kansas Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care - This clinical guideline is intended to provide principles to guide prescribing of mental health medications for youth in Kansas and does not supersede provider clinical judgment. In addition, the parameters may differ from Kansas Drug Utilization Review Board drug coverage guidelines.
  
• PCSP and Completing the PCSP Signature Addendum (PDF) - direction on completing the Person Centered Service Plan. This process is for services not billed through AuthentiCare.

• Sunflower Payment Policy Manuals

General Forms

• PCP Change Form
  • PCP Change Form English (PDF)
  • PCP Change Form Spanish (PDF)
• Office Visit Checklist - Give this to your patients before their appointments to help create a more thorough conversation and encourage patients to plan ahead and focus on any health changes or issues.
  • Office Visit Checklist (English) (PDF)
  • Office Visit Checklist (Spanish) (PDF)
• Member Dismissal Form (PDF)
• Unsolicited Overpayments, Refunds Worksheet (XLS) - Providers have the responsibility to report “unsolicited” overpayments or improper payments to Sunflower Health Plan. (See the related bulletin.)
• EPSDT Medical Necessity Form (PDF)

Consent Forms

• Abortion Necessity - Opens on KMAP page, under the Consent heading
• Consent for Sterilization - Opens on KMAP page, under the Consent heading
• Hysterectomy Necessity (PDF)

Authorization Forms

• Inpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorizaton (PA) Supplemental Form (PDF) This is an optional page meant to be used in conjunction with the Sunflower Outpatient Prior Authorization form when a request exceeds more than four procedure codes.  This page should never be submitted alone.

Pregnancy and Birth Forms

• Notification of Pregnancy (PDF) (System form available through provider portal)
• Birth Event Outcomes Notification (PDF) - Optional form to report birth events/outcomes.

Other Forms

• Integrated Life Plan (PDF)
• Care Grant Request Form (PDF) - used to request care grants for foster care members.
• Lock-In Beneficiary Referral (PDF)

General Forms

• Member Dismissal Form (PDF)
• Unsolicited Overpayments, Refunds Worksheet (XLS) - Providers have the responsibility to report “unsolicited” overpayments or improper payments to Sunflower Health Plan. (See the related bulletin.)
• EPSDT Medical Necessity Form - Opens on KMAP page, under KBH - EPSDT heading 

BH Forms

• Discharge Consultation Documentation (PDF)
• Behavioral Health UM Inpatient Request (PDF) - use this form for all KanCare MCOs.
• PRTF Concurrent Review Form (PDF) - Psychiatric Residential Treatment Facilities (PRTF) CCR form

Authorization Forms

• Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
• Neuropsychological Testing Authorization Request Form (PDF)
• Outpatient Psychological Testing Authorization Request Form (PDF)
• Outpatient Treatment Request Form (PDF) - Behavioral health
• SUD Services Request Form (PDF)
• Psychiatric Residential Treatment Facilities (PRTF) Prior Authorization Request (DOCX)
• Autism Authorization Request Form (PDF)
• Prior Authorization for Supported Housing Operation Community Integration (OCI) Program (PDF)
• Parent Management Training Oregon Request Form (PDF)

• Provider Reconsideration and Appeal Form (PDF)
• Provider Request for External Independent Third Party Review (EITPR) Form (PDF) - Updated June 11, 2021
• Authorized Representative Designation Form (PDF)

• Express Scripts MAC Pricing Inquiry Form
• Synagis PA Form (PDF)
• Other pharmacy forms - including medication and biopharmacy medication request forms

• DME Invoice Pricing Supplemental Form - Find the form under the DME heading.
• EPSDT Medical Necessity Form - Opens on KMAP page, under KBH - EPSDT heading