New Blue KC Provider Reference Guide Now Available

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP1	SMALL GROUP ACA	JAA2	FEP3	Medicare Advantage (BlueCard)4	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

1. ¹ ACA QHP: Affordable Care Act Qualified Health Plan for Individual/Family
2. ² JAA: Joint Administrative Account
3. ³ FEP: Federal Employee Program
4. ⁴ Medicare Advantage (BlueCard): Medicare Advantage for other Blue Cross Blue Shield Association plans

New Blue KC Provider Reference Guide

The new and enhanced Provider Reference Guide (PRG) can be found by logging into Providers.BlueKC.com and clicking on Resources. Multiple documents have been consolidated into a single primary PRG with a supporting Blue Card manual, which can also be found on the Resources page. Various policies and procedures have been updated and/or revised. The Blue KC Provider Reference Guide includes information about administrative areas, including policies, programs, quality standards, appeals and more.

Back to Top

Payment Policy Updates

To find the complete version of Blue KC Payment Policies, click here or go to the login page at Providers.BlueKC.com and click on “Go to Payment Policies”, which lists All Provider Payment and Coding Policies and Lab Payment Policies.

Payment Policies Featured in this Section

Revenue Codes Requiring HCPCS Codes

Billing of Applied Behavior Analysis and Speech, Occupational and Physical Therapies

Electroencephalogram (EEG) Video Monitoring

IOP, PHP, and Inpatient treatment Services for Substance Abuse and Psychiatric

Modifier AS Assistant Surgeon

Revenue Codes Requiring HCPCS Codes Payment Policy

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP1	SMALL GROUP ACA	JAA2	FEP3	Medicare Advantage (BlueCard)4	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-229	Revenue Codes Requiring HCPCS Codes Payment Policy	4/1/2026	4/1/2026	View our Revenue Codes Requiring HCPCS Codes Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates Added

• This update does not apply to inpatient claims and will be effective for dates of service on or after April 1, 2026.
• Revenue code and procedure code combinations that are submitted on outpatient claims should reflect the services that were provided to the member on that date of service.
• These codes should be submitted on the same line for accurate claims processing.
• If more than one HCPCS or CPT code is needed for a revenue code, the revenue code should also appear on a separate line.
• Billing and Coding Revenue code(s) and corresponding procedure code(s) must be compatible.
• Blue KC may deny an outpatient facility claim if a revenue code is submitted without the appropriate procedure code(s) when submitted on the following bill types:
  • 12x 13x, 14x, 74x, 75x, 76x, 83x, 84x, 85x, and 89x
  • These are procedure and revenue code combinations that are not appropriate when billed together.
• Evaluation and Management services codes 99202-99249, G0380-G0184 and G2212 when submitted with revenue codes 0760, 0761 and 0769 (specialty services) will be denied.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-229	Revenue Codes Requiring HCPCS Codes Payment Policy	4/1/2026	4/1/2026	View our Revenue Codes Requiring HCPCS Codes Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates Added

• The following guidelines will be enforced for Revenue code 0710 Recovery Room, effective for dates of service on or after April 1, 2026:
  • Revenue code 0710 requires a CPT/HCPCS code to be submitted in addition to the revenue code. When a CPT/HCPCS code is not submitted with revenue code 0710, it will be returned to the facility due to incomplete or incorrect data.
  • The typical average time spent in recovery is 1 to 3 hours. Recovery room time submitted with over 300 units (5 hours) will be denied for review. Documentation will be required to support the patient was unstable/experiencing complications and the additional time was medically necessary.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-229	Revenue Codes Requiring HCPCS Codes Payment Policy	2/1/2026	2/1/2026	View our Revenue Codes Requiring HCPCS Codes Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates Added

• The following guidelines will be enforced for Revenue code 0710 Recovery Room, effective for dates of service on or after February 1, 2026:
  • Revenue code 0710 is allowed on the day of surgery/procedure and is not allowed to be billed on multiple days.
  • Time should be billed in units: 60 minutes is 60 units.
  • Recovery Room time stops when a patient's vital signs are stable, they are fully alert and medically cleared to move to a regular hospital room or go home.

Billing of Applied Behavior Analysis and Speech, Occupational and Physical Therapies Payment Policy

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Policy Number	Policy Name	Effective Date for New Policy	Enforcement Date for New Policy	Full Policy Location
POL-PP-329	Billing of Applied Behavior Analysis and Speech, Occupational and Physical Therapies	4/1/2026	4/1/2026	View our Billing of Applied Behavior Analysis with Speech, Occupational and/or Physical Therapy Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

New Summary Policy

• Below is a summary for new Blue KC Payment Policy, Billing of Applied Behavior Analysis and Speech, Occupational and Physical Therapies, that will be effective for dates of service on or after April 1, 2026.
• Concurrent care exists where more than one healthcare provider renders services during a period of time.
  • When Concurrent or Overlapping Billing is Allowed:
    • The following procedure codes, 97153 and 97155, may overlap, as long as the descriptors of each code have been met and different qualified health providers (QHPs) deliver the service.
    • A single provider may NOT bill these codes concurrently.

Modifier	Description
HM	Modifier HM indicates that a service was performed by a provider with less than a bachelor's degree. This modifier is most often used in the billing of behavioral health services, including Registered Behavior Technician
HO	Modifier HO Indicates a master's-level professional, such as a Board-Certified Behavior Analyst (BCBA) or licensed mental health provider

• When Concurrent or Overlapping Billing is Not Allowed:
  • Billing applied behavior analysis (ABA) services when performed in the same block of time as speech, occupational and/or physical therapy, are not allowed.
  • Billing standards require only one service and one provider to be designated for a given time. For example:
    • If a member receives ABA therapy with a registered behavior technician (RBT) and occupational therapy with an occupational therapist from noon to 1 p.m., this is considered overlapping time and is not allowed.
    • If the member receives ABA therapy with an RBT from noon to 1 p.m. and occupational therapy from an occupational therapist from 1 p.m. to 2 p.m., these are not overlapping, and both services are billable. The billing of these services on the same day as ABA is allowed, but not during the same given time.

Electroencephalogram (EEG) Video Monitoring Payment Policy

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Policy Number	Policy Name	Education	Full Policy Location
POL-PP-227	Electroencephalogram (EEG) Video Monitoring		View our Electroencephalogram (EEG) Video Monitoring Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Education

• Observation code G0378 should not be used for EEG monitoring. Monitoring is included in the CPT code that represents the technical component.
• For EEG services without Video monitoring, see codes 95705 – 95710 (facility) and 95717, 95719, 95721, 95723 and 95725 (professional).
• Inpatient admission may be necessary when monitoring goes beyond 48 hours for patients, such as those with seizures that are infrequent, clinically severe (such as prolonged complex partial seizures) or are provoked by drug withdrawal.

IOP, PHP, and Inpatient treatment Services for Substance Abuse and Psychiatric Payment Policy

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-238	IOP, PHP, and Inpatient treatment Services for Substance Abuse and Psychiatric	4/1/2026	4/1/2026	View our IOP, PHP, and Inpatient treatment Services for Substance Abuse and Psychiatric Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates Added

• Effective for dates of service on or after April 1, 2026, the following condition codes will be required:
  • Partial Hospitalization claims will be required to use condition code 41 indicating Partial Hospitalization Program (PHP).
  • Intensive outpatient claims will be required to use condition code 92 indicating Intensive Outpatient Program (IOP) services.

Modifier AS Assistant Surgeon Payment Policy

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Policy Number	Policy Name	Education	Full Policy Location
POL-PP-242	Modifier AS Assistant Surgeon		View our Modifier AS Assistant Surgeon Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Education

• The primary surgeon should not submit an assistant surgeon claim under his or her name.
• The Advanced Practice Provider Billing Payment Policy states claims are to be submitted under the name and NPI number of the provider who rendered the service.

Back to Top

Pharmacy Policy Updates

New Pharmacy Policies

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Here are new Blue KC pharmacy policies for medication that will require prior authorization, effective February 1, 2026:

New Pharmacy Policies
Policy Number	Policy Name	Summary
5.02.691	PD-1 and PD-L1s	New policy replaces individual polices for Bavencio, Imfinzi, Jemperli, Keytruda, Libtayo, Loqtorzi, Opdivo, Opdualag, Tecentriq, Tevimbra, Zynyz
5.02.692	Lynozyfic (linvoseltamab-gcpt)	FDA approved for Relapsed or refractory (R/R) multiple myeloma (MM); IV: Medical-Rx benefit

Pharmacy Policies with Changes

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Below are Blue KC pharmacy polices with changes for medication that will require prior authorization, effective February 1, 2026:

Pharmacy Policies with Changes
Policy Number	Policy Name	Summary
5.02.508	Stelara (ustekinumab) and Biosimilars	Yesintek IV and Otulfi IV are the preferred biosimilars. Must step through both before coverage of Stelara or other biosimilars.
8.01.05	Immune Globulin Therapy	Added Yimmugo and Qivigy to list of non-preferred IG products
5.02.668	Imdelltra (tarlatamab-dlle)	Added med necessity criteria that member has ES-SCLC that has metastasized to the brain
5.01.823	Cyramza (ramucirumab)	Removed combination use of Cyramza and Pembrolizumab for NSCLC
5.02.669	Reblozyl/Rytelo Step Policy for Anemia due to Myelodysplastic Syndromes	Added criteria regarding ring sideroblasts
5.01.24	Rituximab and Biosimilars	Preferred products changing from Ruxience and Truxima to Riabni and Truxima

Commercial Formulary Updates

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Effective January 1, 2026, updates were made to the Blue KC Commercial Prescription Drug Lists, including our Premium, Select and the Essential Health Benefits (EHB) Prescription Drug Lists, which is also utilized by our ACA QHP for Individual/Family and Small Group ACA.

For details, refer to the Pharmacy Policy Updates article in our December 2025 BlueSpeak Newsletter, which can be found by logging into our Provider Portal, clicking on the Communications tab in the Resources section and looking under the BlueSpeak archive.

Medical Policy Updates

The most up-to-date Medical Policy can be found by logging into Providers.BlueKC.com and clicking on the Medical Policies section. 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, MCG and eviCore.

Blue KC Medical Policy Updates

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Effective date – 2/1/2026

ID: APEA – G2119 Title: Diagnostic Testing of Influenza Coverage Criteria 1: Edited for clarity; added reference to new Note 2 (referenced below). Note 1: Updated signs and symptoms of the flu to align with the CDC. New Note 2: One influenza test may detect influenza A and/or influenza B. When both influenza A and influenza B are detected by a test represented by CPT codes 87400, 87501 or 87804, up to two units may be billed at a single visit.

Effective date – 2/1/2026

ID: APEA – G2113 Title: Oral Cancer Screening and Testing Added “or with metastatic squamous cell carcinoma of unknown primary origin in a cervical lymph node” to Coverage Criteria 1, now reads: “1) To establish HPV tumor status for individuals with oropharyngeal squamous cell carcinoma or with metastatic squamous cell carcinoma of unknown primary origin in a cervical lymph node, testing for high-risk HPV with either mRNA expression testing for HPV E6/E7 or immunohistochemistry for p16 expression is considered medically necessary.” New Coverage Criteria 2.e.: “e) Detection of HPV from an oropharyngeal swab (e.g., OmniPathology Oropharyngeal HPV PCR Test).”

Back to Top

Prior Authorization Updates

Reminder: OncoHealth Assists Blue KC’s Prior Authorization Process for Oncology Treatments

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

As a reminder, Blue KC has partnered with OncoHealth, a leading oncology organization, to administer prior authorization for oncology treatments for dates of service on or after January 1, 2026. This change is designed to streamline processes and deliver support for our members with cancer. Note: Oncology treatments already authorized by Blue KC before January 1, 2026, will remain in effect until their approved end dates and will not need to be resubmitted to OncoHealth unless there is a change in treatment or renewal.

OncoHealth is assisting Blue KC’s prior authorization process for radiation therapy and oncology drugs that will require prior authorization for Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business. Blue KC will post new medical policies and updates to existing policies related to this partnership with OncoHealth. Click here for the Blue KC Medical Policies landing page, or you may visit our log-in page at Providers.BlueKC.com and click on Go to Medical Policies.

For more details, including a list of impacted codes and resources, click here or log into the Blue KC Provider Portal at Providers.BlueKC.com and look under Recent News on the home page.

Code Additions

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

The following code will be added to our prior authorization list, effective March 1, 2026:

Code	Description	Effective Date	Lines of Business Impacted
E0694	Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer and eye protection	3/1/2026	Commercial (already requires prior authorization for ACA)

Back to Top

Provider Data Updates

Reminder: Enhanced General Inquiry Form

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Blue KC is excited to bring you a more efficient and streamlined General Inquiry Form for a faster way to answer your questions!

View the form (pictured with this article) or visit Providers.BlueKC.com, click Contact on the top right and select General Questions under Support & Services.

You may be directed to our provider hotline or asked to log into Providers.BlueKC.com and select Forms under Quick Links on the home page to submit one of our other helpful forms, such as:

• Provider Updates Form
  • For updates in between initial credentialing and re-credentialing cycles
• Initial Credentialing Forms
  • For solo/rendering practitioners and ancillary/facility providers new to Blue KC.
• Revalidation Credentialing Forms
  • For existing solo/rendering practitioners and ancillary/facility providers.

For non-contracted provider groups, ancillaries and facilities interested in joining Blue KC’s networks, select “Join Blue KC Networks” on our login page at Providers.BlueKC.com.

For claims related inquiries, please use the Claim Inquiry Form (Providers.BlueKC.com/eForms/Form/ClaimInquiry), which provides the following category options:

You are also able to use this Claim Inquiry form to request the status of a previous inquiry if a response has not been received within 30 days.

Back to Top

Provider Education

High-Cost /claims Process Reminder

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Blue KC began the Prepayment Diagnosis Related Group (DRG) and Clinical Chart Validation Review for dates of service on or after January 1, 2026. Blue KC notified facility partners in June 2025, and this information was communicated in the September 2025 BlueSpeak Provider Newsletter to ensure providers have time to make any necessary process or system changes in preparation to submit itemized bills and medical records to Blue KC.

• In addition to Blue KC’s existing itemized bill review process for discounted charge claims, Blue KC expanded the scope of these reviews to include coding and clinical validation review of facility claims with a DRG payment methodology.
• This review is not based on medical necessity. Clinical validation is a distinct and separate process from coding validation.
• Blue KC requires submission of itemized bills with all facility claims with a billed charge of $100,000 or more with a reimbursement methodology of DRG, DRG outlier or discounted charges for inpatient and outpatient claims.
• Medical records and/or itemized bills may also be requested as needed to support Blue KC payment integrity audits.
• Review will likely be triggered by cases involving Sepsis, Major Complications, or Atypical Complications.
• When a medical record and/or itemized bill is required for these high-cost claims and is not submitted, the claim will be denied, and a letter will be generated requesting additional information.
• A new or corrected claim does not need to be submitted because the claim will be reconsidered upon receipt of the additional information from the provider.

As a reminder, all claim submissions must adhere to all applicable medical coding guidelines and Blue KC medical and payment policies.

• Please continue to fax the itemized bill to 816-995-1552 for both inpatient and outpatient claims.
• Medical records should be faxed to 816-926-4258.
  • Include the patient’s Subscriber ID number.
  • At this time, the attachments cannot be submitted electronically with the claim.
  • The claim may not be faxed to the number above, but it can be submitted electronically.

Criteria for this process is:

• Payment methodology for the claim is based on percentage of billed charge or DRG/DRG Outlier for inpatient or outpatient claims.
• Interim claims are included for non-Blue KC Members.
• Transplant claims are excluded.
• Claims in which Blue KC is the secondary payer are excluded.
• Interim claims are excluded for Blue KC members, until the final billing is submitted. At that time, the itemized bill should also be submitted.

If you have any questions or require additional information, please feel free to contact your Blue KC Provider Account Executive. To find a DRG coding tip sheet, log into Providers.BlueKC.com and look under Recent News on the home page. Blue KC thanks you in advance for your cooperation and assistance.

February Free Documentation & Coding Webinar

LINES OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
BLUE highlighted boxes are the lines of business impacted by this update.

Join us for the February monthly webinar hosted by our partner, Veradigm! This is a free documentation and coding education webinar. Each 1-hour webinar is approved for one AAPC CEU when you achieve a 70% or higher on the post-test. To register for the webinar, click here for details:

February 24 & 26 7:30 am & 11:30 am CT

Coding Chaos: Making Sense of Autoimmune Codes

Dive into the complexities of autoimmune disorders and explore key documentation and coding strategies for autoimmune conditions like Rheumatoid Arthritis, Multiple Sclerosis, Psoriasis and more.

Back to Top

Community Investment

Two days before New Year’s Day 2026, Blue KC employees helped begin transforming an acre of land into a learning farm at DeLaSalle Education Center near 37th and Troost in Kansas City, MO.

The group installed about a dozen raised garden beds, which will be used to grow healthy food this spring. Plans for the multi-year learning farm project include the building of an orchard, duck pond, rabbit hutch, chicken coop and outdoor eatery.

Thanks to a partnership between Blue KC, behavioral and mental health nonprofit Cornerstones of Care and its vocational program Build Trybe, the learning farm will also aim to help reduce food insecurity. Click here to learn more.

Back to Top

Contact Us

Please join the BlueSpeak email distribution list by sending a request to BlueSpeak@BlueKC.com. You can also use this email address to give us any feedback about BlueSpeak. We would love to hear from you!

If you have questions about any of these updates, please call the Blue KC Provider Hotline at 816-395-3929 for Commercial line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

Back to Top