Blue Cross and Blue Shield of Kansas City (Blue KC) has discovered instances where Urgent Care facilities have billed a global rate without including a line item for COVID-19 testing. This has caused us to apply member cost-sharing incorrectly. We have decided to adjust these claims based on the member’s verbal confirmation that a COVID test was done instead of requesting medical records to review.
To avoid this issue in the future, we are asking Urgent Care facilities to add the COVID test CPT code on their claims with a zero-dollar amount so our system can track and pay related services correctly. We appreciate your help to make this process as smooth as possible.
Please continue to visit Providers.BlueKC.com using your login user ID and password for the most up-to-date information about policies, coding, billing and other operational details related to COVID-19. Thank you again for your partnership in providing quality care to our members.
COVID-19 VACCINE S.A.F.E. SERIES. In our efforts to promote the COVID-19 vaccine, Blue KC created the COVID-19 Vaccine S.A.F.E. Series to address the impact of COVID-19 on the Black community and emphasize the health benefits of receiving the vaccine.
The S.A.F.E. series includes five factual, educational interviews with community leaders showing how the COVID-19 vaccine is not only Safe, but also Simple, Accessible, Free and Easy.
The interviews feature Samuel U. Rodgers Health Center Chief Medical Officer Dr. Toni Zink, Kansas City Chiefs Hall of Famer Bobby Bell, Black Health Care Coalition President Melissa Robinson and Kansas City, MO Health Department Director Dr. Rex Archer. You can view the series by clicking here.
COVID-19 COMMUNITY RESPONSE. No one should have to feel hungry, and the need for food has never been greater than during the COVID-19 pandemic. Our Live Blue Kitchen + Café, which typically feeds hundreds of Blue KC employees daily, donated 63,750 meals to community partners in 2020 and 2021. The donation is part of Blue KC’s Well Stocked initiative, which seeks to address food insecurity throughout Kansas City.
“Blue KC has always been committed to improving community health, and we’ve stepped up since the beginning of the pandemic to respond to the increased need in our community,” said Live Blue Kitchen + Café Executive Chef Kyle Williams. “I’m proud to be part of their Well Stocked efforts, contributing the best way I can, by using my specialty in healthy food to make a meaningful difference.”
Live Blue Kitchen + Café meals have been delivered to multiple organizations in the region including Veterans Community Project, Mercy and Truth, Urban League, Operation Breakthrough, Our Spot KC, New House, Meier Hoffer Senior Center, Literacy KC, Tri-County Mental Health, Mothers Refuge, Hillcrest Transitional Housing, Police Athletic League, Phoenix Family, Ronald McDonald House Charities and KC Dream Center. Click here to learn more about Well Stocked and other Blue KC community initiatives.
SHUT OUT THE STIGMA. Blue KC hopes to hit a home run when it comes to facing the issue of behavioral health. As the “Official Health Insurance Provider of the Kansas City Royals,” we have teamed up with the Royals to launch the Shut Out the Stigma campaign, which will continue throughout the 2021 season.
The Royals and Blue KC are creating awareness for specific behavioral health concerns, sharing real-life stories from inside the Royals organization and providing resources for those seeking help with their behavioral health.
For the rest of the 2021 season, each time the Royals win a game in a shutout, which means the other team does not score, Blue KC will donate $10,000 to support behavioral health services in the Kansas City community. Click here for more information.
MINDFUL BY BLUE KC TO SUPPORT YOUR PATIENTS. What if there was a way to reach someone on the phone 24/7 for behavioral health support? Blue KC has a program that offers that type of service. We are thinking differently about care and coverage by enhancing services provided in member health plans. Mindful by Blue KC is a behavioral health initiative dedicated to addressing access and reducing stigma to support the behavioral health needs of our members.
Blue KC members have access to a variety of services and tools to address depression, anxiety, substance use and everyday challenges. By calling one number, 833-302-MIND (6463), members can get in-the-moment support and care navigation, help locating and referring to in-network providers or assistance connecting to expedited treatment options in crisis situations.
Livongo for Diabetes
Blue KC has partnered with Livongo with one goal in mind: To make living with diabetes easier. The partnership allows us to keep quality care available to our members dealing with diabetes, whether at home or in the clinical setting. Click on the image below to watch the video and learn more:
Your patients can register online or by calling (800) 945-4355 and using Blue KC as the registration. If you have questions, please call 816-395-2222, ext. 8283. As always, thank you for your participation in our networks.
Blue KC Member ID Card with Spira Care Logo
If a patient arrives at your practice with a Blue KC member ID card that has a Spira Care logo, does that mean he or she will be out-of-network to you? We have received calls and questions on this subject and want to clear up any confusion. Look to see if your practice is contracted with one of the following Blue KC Networks listed below. If you are contracted with a network below and that network is also displayed on the member ID card, you would be considered in-network for the member.
Blue KC members enrolled in plans with access to Spira Care Centers also have access to their plan’s network within the Kansas City metro area and the nationwide BlueCard network (except for Individual ACA plans) for care when traveling outside of their service area.
View the member’s ID card to find out if their plan is an EPO or PPO insurance model:
SPIRA CARE MEMBER, EXCLUSIVE PROVIDER ORGANIZATION. In the Exclusive Provider Organization (EPO) option, members must receive all care from in-network providers (Blue Select Plus network in the Kansas City area or BlueCard network outside the 32-county service area excluding Individual ACA plans) except for emergency services. Non-emergency services received out-of-network will not be covered. Please ensure you refer members to other participating Network providers.
SPIRA CARE MEMBER, PREFERRED PROVIDER ORGANIZATION. In the Preferred Provider Organization (PPO) Spira model, members are encouraged to receive care from in-network providers (BlueSelect Plus network in the Kansas City area or BlueCard network outside the 32-county service area) but have the option to receive care from out-of-network providers at a higher cost.
Medical Policy Updates
The most up-to-date Medical Policy can be found here. While on that web page, you can also find a link to view Milliman Care Guidelines (MCG), which complement our Blue KC policies.
The Blue KC Medical Policy encompasses internal Blue KC Medical Policy, Blue Cross Blue Shield Association derived Medical Policy and policies adopted from our vendor partners, such as Avalon (APEA), MCG and EviCore.
|New Blue KC Policy|
|Effective date – 6/1/2021||AHS-M2177 Fibromyalgia Testing|
|New MCG Guideline|
|Effective date – 6/1/2021||BKC-SG-MS Musculoskeletal Surgery or Procedure GRG|
Pharmacy Policy Updates
Three oncology drugs have undergone Medical Policy updates. The changes to Avastin, Herceptin and Rituxan medical policies were effective June 1, 2021 and require prior authorization.
|The updates impact our commercial line of business and do NOT apply to Federal Employees Program, Joint Administrative Account, Blue Medicare Advantage or individual Affordable Care Act plans.|
|The Avastin, Herceptin and Rituxan policies will require a trial of at least one preferred biosimilar product before an originator product authorization.|
|This applies to oncology indications only for which the biosimilar has been FDA-approved and is supported by National Comprehensive Cancer Network (NCCN) Guidelines or NCCN Compendium.|
|For Avastin, members will be required to try preferred Mvasi or Zirabev before non-preferred Avastin.|
|For Herceptin, members will be required to try Kanjinti, Ogivri or Trazimera before non-preferred Herzuma, Ontruzant or Herceptin|
|For Rituxan, members will be required to try preferred Ruxience or Truxima before non-preferred Riabni or Rituxan.|
|These changes were applied to patients new to therapy as of June 1, 2021 and require prior authorization. Members with an existing authorization for a non-preferred product will be allowed to continue their therapy uninterrupted.|
Preferred Formulary Updates
We want to let our contracted providers know of updates to the Blue KC Preferred Prescription Drug List that will go into effect on July 1, 2021.
The Blue KC Medical and Pharmacy Management Committee reviews and maintains the Prescription Drug List. The Committee, consisting of practicing physicians and pharmacists in the Kansas City area, holds quarterly meetings to evaluate new drug therapies and review drug utilization issues. Medications are evaluated based on drug safety and costs.
These updates only impact our commercial line of business. Group-specific benefit exceptions may apply. Blue Medicare Advantage (MA) and ACA Qualified Health Plans (QHP) are not impacted. These changes do NOT apply to members using the Premium formulary.
How We Will Communicate These Changes
Blue KC is taking proactive steps to limit disruption, including:
- Impacted members will receive a letter notifying them of the changes.
- All in-area providers will be notified by letter in the event their patients contact them to discuss alternative medications.
New Step Therapy Requirements
- Members must try preferred alternative(s) before other drugs will be covered.
- Exceptions can be requested through the prior authorization process.
- *Members currently utilizing these drugs will be grandfathered on therapy.
|New Step Therapy Requirements|
|Drug Class||Drugs Requiring a Trial of Alternative(s)||Preferred Alternative(s) (Try First)|
|Acne, psoriasis||Acne, psoriasis Fabior, Tazorac, tazarotene Topical tretinoin||Topical tretinoin|
|Anaphylaxis Agents||Epipen, Epipen Jr, Auvi-Q .15MG, 0.3MG Epinephrine, epinephrine auto injector||Epinephrine, epinephrine auto injector|
|Antipsychotics||Caplyta*, Fanapt*, Saphris*, Secuado*, Vraylar*||At least TWO generics: aripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine IR/ER, risperidone, ziprasidone|
|Antiretrovirals||Truvada||Generic emtricitabine-tenofovir disoproxil fumarate|
|Atopic dermatitis||Protopic, Elidel, pimecrolimus||Generic topical tacrolimus ointment|
|Contraceptives||Twirla||An oral contraceptive AND a contraceptive patch|
|Multiple Sclerosis||Plegridy*, Gilenya*, Rebif*||At least TWO of the following: Avonex, Bafiertam, Betaseron, Copaxone/glatopa, Kesimpta, Vumerity|
|Tecfidera||Generic dimethyl fumarate|
|Otic Agents||Ciprodex||Generic ciprofloxacin-dexamethasone otic suspension|
|New Prior Authorization Requirements|
|Drug Class||Drugs Requiring Prior Authorization|
|Interstitial Cystitis Agents||Elmiron|
Tier Changes Increasing Member Copayment
- Members will now be required to pay Tier 3 cost sharing for the following medications.
|Medications moving from Tier 2 to Tier 3|
Same Policy, Different Name
Our Never Events payment policy has been renamed Serious Adverse Events to include both Serious Reportable Events (aka Never Events) and CMS-defined Hospital Acquired Conditions. We previously announced that effective May 15, 2021, Blue KC will not reimburse contracted health care providers for Serious Adverse Events
For additional information on what constitutes a Serious Adverse Event, view the payment policy on the Blue KC Provider Portal by clicking here.
Important Reminder: ASC Updated Billing Guidelines
Blue KC wants to inform you of an important update to billing policies for Ambulatory Surgery Centers (ASCs).
To ensure correct payment according to contractual agreements, the previously announced billing changes that were set to go into effect on July 1, 2021, will no longer take place. You can continue billing for services the way you have been doing since January 1, 2021, for all commercial and ACA lines of business until further notice.
- For dates of service in 2021 and until further notice, ASCs providing services to Blue KC’s commercial and ACA members are required to bill services on the UB 04 claim form—this is the same process that was done before 2021.
- Reminder: Effective January 1, 2021, and until further notice, ASCs providing services to Blue Medicare Advantage members are required to bill those services on the HCFA 1500 claim form to comply with requirements from the Centers for Medicare and Medicaid Services (CMS).
Important Reminder: PA Updates for MA and ACA Plans
Updates are on the way to our prior authorization list for Blue Medicare Advantage (MA) and Affordable Care Act (ACA) plans.
- These five codes will be added July 1, 2021, and apply only to MA and ACA plans:
|64479||Inj Foramen Epidural C/T|
|64480||Inj Foramen Epidural Add-On|
|64483||Inj Foramen Epidural L/S|
|64484||Inj Foramen Epidural Add-On|
Go to the Medical Services tab at this link for our current prior authorization lists. The codes noted above will appear on the website by July 1, 2021.
- Please note that Blue KC requires you to schedule non-emergency procedures 14 days after prior authorization is requested. We thank you for your help in cooperating with this policy.
If you have questions, please call Blue Medicare Advantage Customer Service at 1-866-508-7140 or the Affordable Care Act Provider Hotline at 1-866-859-3822.
Important Reminder: SNF Waiver of PA Request
Blue KC’s extension of the in-network Skilled Nursing Facilities’ (SNF) waiver of prior authorization for commercial and Blue Medicare Advantage members runs through September 30, 2021. The SNF waiver extension excludes ACA Qualified Health Plans (QHP).
This waiver assists facilities with freeing up their in-patient beds as quickly as possible and is not tied to COVID-19. Blue KC encourages you to accept these admissions without waiting for prior authorization. Please share this communication with your staff to ensure quality and efficiency. We will continue to evaluate the success of this program and reserve the right to modify if needed.
We are receiving a high volume of SNF authorization requests marked “Expedited,” “Urgent” or “Stat.” Typically, requests for SNF admissions are “Standard.” In general, very few scheduled prior authorization requests meet the definition of “Expedited.”
|The waiver only applies to in-network SNF admissions from acute hospitals. A positive COVID-19 diagnosis is NOT REQUIRED.|
|Exclusions from waiver: Any admission to a swing bed, SNF-to-SNF transfers, SNF admissions from other settings such as home or Long-Term Care, Inpatient Rehab and Long-Term Acute Care (LTAC). These circumstances require the normal prior authorization process.|
|Any requests for a carve-out due to a high-cost medication or DME item will need to be submitted and either approved or denied by the Plan prior to accepting the member.|
|In accordance with existing policy, intake facilities must notify Medical Management of admissions within 24 hours. Notifications should be sent to Medical Management via fax to (877) 549-1744 for Blue Medicare Advantage and (816) 995-1502 for commercial line of business and include the admit date, facility NPI, physician name and NPI, ICD-10 code(s), clinical documentation and a contact person’s name, phone and fax numbers.|
|If you have any questions regarding the SNF waiver extension of prior authorization, please call Blue Medicare Advantage Customer Service at 1-866-508-7140 or the Blue KC Provider Hotline at (816) 395-3929 for commercial line of business.|
Important Reminder: MA Correspondence
As a reminder, Blue KC made operational changes for 2021 in our Blue Medicare Advantage plans that were previously administered by Lumeris.
For any remaining 2020 claims, please send electronically to Blue KC as soon as possible. As previously communicated, please also submit all claims electronically for 2021 dates of service to Blue KC.
- This communication only applies to Blue Medicare Advantage.
- We encourage you to submit Blue Medicare Advantage claims electronically.
- Please submit all remaining 2020 claims electronically to Blue KC as soon as you can to allow us to process as many claims as possible before our transition from Lumeris.
- In the rare case a paper claim is needed, please use the following address for Blue Medicare Advantage correspondence and medical and behavioral health claims for 2020 and 2021 dates of service: Central Operations (COPS) Blue KC MA, Attention: Government Programs MA, P.O. Box 419169, Kansas City, MO 64141.
- For questions, please call Blue Medicare Advantage Customer Service at 1-866-508-7140.
Important Reminder: Paper Remittance Advice
Beginning in July 2021, your Paper Remittance Advice will feature minor design changes.
The forms have been designed to be better streamlined and will include the same helpful information that you are accustomed to receiving.
There will be no change to the Electronic Remittance Advice.
BCBS of Alabama Adds New Brand
Here is something to look out for on member ID cards next year. In response to customer requests, Blue Cross and Blue Shield of Alabama is introducing a new national accounts brand: Credence Blue Cross and Blue Shield. Credence is a new name for an enhanced approach in serving and supporting national customers for Blue Cross and Blue Shield of Alabama.
The new Credence brand will appear on member ID cards for select national customers beginning January 1, 2022. Blue Cross and Blue Shield of Alabama will continue to be used for the remainder of its business.
National Dental GRID
This news can make dentists smile. Did you know members of participating Blue Cross and Blue Shield plans around the nation have exclusive access to the National Dental GRID? This means more members can turn to you for their dental care because you are in-network for members of participating Blue Cross and Blue Shield plans who live in your area.
The National Dental GRID, administered by the GRID Dental Corporation, has two networks that enable participating network dentists to see members from participating Blue Cross and Blue Shield plans at their local-plan reimbursement levels. GRID and GRID+ provide a competitive network solution in the marketplace that is well-positioned as one of the largest fee-for-service networks operating nationwide.
Your participation in the national Dental GRID does not change your reimbursement levels or participating provider agreement in any way. You can continue to be reimbursed based on your current participating provider agreement.
The National Dental GRID has been available to employer groups since January 2012. Blue KC joined effective January 1, 2017.
How to Recognize a GRID Member
- On the back of the member’s dental-only ID card or his or her combined medical-dental ID card, you should see the word “GRID” or “GRID+,” along with a Customer Service number to contact for benefit or eligibility questions.
- If a member states that he or she has access to the GRID or GRID+ network, but neither word is listed, please call the Provider Service Customer Service phone number on the KD card to verify participation. A small number of participating plans may not immediately update their member ID cards to add the words “GRID” or “GRID+.”
GRID and GRID+ Reimbursement Levels Compared to Blue KC Reimbursements
- GRID reimbursement levels are equal to PPO reimbursement levels. GRID+ reimbursement levels are equal to Choice reimbursement levels.
Where to Send Claims for GRID and GRID+
- Send claims to the address on the member’s ID card. Please check the front or back of the card for address information.
- Claims are paid by the participating plan where the member’s group is located, but reimbursement is at your PPO or Choice Level.
- Questions? Contact a network representative at Dental@BlueKC.com.
Provider Data Management
We appreciate your help with our provider data management requirement that went into effect on January 1, 2021:
- Blue KC requires your provider taxonomy to be reported on all claims. Contact your clearinghouse partner to confirm you currently send the provider taxonomy to Blue KC on your electronic claims. If you do not currently send the taxonomy to your clearinghouse partner, you may need to contact your EHR vendor to ensure the setting is turned on and is mapped to the correct loop and segment message to your clearinghouse partner.
- Claims will reject at the Administrative Services of Kansas (ASK) clearinghouse partner if the Taxonomy code is missing.
Below are three options to update your provider data management information:
Blue KC participates in the DirectAssure quarterly attestation process required by CMS. This allows providers to update their information for multiple private payors in a single platform and can be used for non-delegated and delegated providers. Please log in to CAQH ProView and correct the provider information. Please log in to CAQH each quarter to stay compliant with CMS regulations.
Updating provider information in the NPI Registry through NPPES is essential. Additionally, adding your CMS and Medicaid numbers will reduce payor inquires for this information.
This is the central provider enrollment database for CMS. PECOS supports the Medicare Provider and Supplier enrollment process by allowing registered users to submit and manage Medicare enrollment information securely and electronically. Please ensure providers are linked to the correct groups, and hospital affiliations are accurately reflected.
Note: Per CMS regulations, we will make outbound calls to provider facilities and offices each quarter to make sure we have your most current information.
Important Provider Information
Blue KC wants to make sure you have important information related to five key areas.
- Member Rights and Responsibilities: Blue KC members have certain rights and responsibilities. For a complete list of the Blue KC Member Rights and Responsibilities, click here.
- Utilization Management Policies: Medical and Pharmacy review criteria, along with medical policies, are available here or by calling 816-395-3989.
- Pharmacy Services: Pharmacy Management policies and current information regarding classes of medications requiring prior authorization, step therapy, specialty pharmacy and/or having dose optimization/quantity limits are available by logging into the provider portal. In addition, information regarding prescription drug lists, explanations on limits/quotas, instructions on initiating an exception request, and the Blue KC protocols and processes for generic substitution, therapeutic interchange and step therapy are accessible by logging into the provider portal or by contacting Pharmacy Services at 816-395-2176.
- Special Notice – How Utilization Management (UM) Operates: Blue KC’s Population Health division, Pharmacy Services, participating network physicians and providers make decisions about Blue KC members’ healthcare needs based on the medical appropriateness of the care and service. Our goal is to identify and promote cost effective usage of healthcare resources to ensure that quality healthcare services are delivered to our members. Criteria is available upon request. Blue KC does not reward its Utilization Management (UM) staff for issuing denial of coverage decisions. There are no financial incentives to UM staff or medical directors to make decisions that would encourage underutilization of services. Click here to learn more.
- Complex Case Management: Information on our Complex Case Management Program, including referral criteria, and how to refer patients to the Program can be found here.
Provider Reference Guide
Hot off the Press! The Blue KC First Quarter 2021 Provider Reference Guide (PRG) has been released. The updates to the PRG include a new summary page that outlines additions and changes to policies and procedures available to your practice or facility.
To view the PRG, click here.
What if you could have a say in how Blue KC conducts business and also have a chance to win an Apple Watch? It is all part of our electronic Provider Satisfaction Survey we sent to you in a recent email.
If you are unable to find the survey in your email, you can access it here. The survey allows you to provide feedback on changes to the provider portal, prior authorization process and overall satisfaction with Blue KC support. Plus, see the end of the survey for the opportunity to enter a prize drawing for a chance to win an Apple Watch.
Kindly share the survey email with others at your organization who interact with Blue KC. We ask that you please complete the survey by Friday, June 25.
We value and appreciate you as our partner in providing quality care. Your comments are welcome and can be sent to BlueSpeak@BlueKC.com.
Anyone can join the BlueSpeak email distribution list by signing into the provider portal and then selecting “Register for BlueSpeak eNewsletter” under “Provider Service Quick Links” on the home page.
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