Prior Authorization Updates

New August 1, 2024 Go-Live Date: Blue KC Musculoskeletal Surgical Quality and Safety Management Program in Partnership with TurningPoint

Blue KC is pleased to launch a new and innovative Musculoskeletal Surgical Quality and Safety Management Program with TurningPoint Healthcare Solutions, LLC, who will partner with Blue KC to oversee prior authorization requests on Musculoskeletal Surgical Procedures. The program will now be effective on August 1, 2024, and is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for our members receiving Musculoskeletal Surgical Procedures.

• The program will impact the following lines of business, effective August 1, 2024: Commercial, Blue Medicare Advantage, ACA QHP for Individual/Family and Small Group ACA. Blue KC will adopt TurningPoint’s Medical Polices for all applicable prior authorization requests for all other lines of business, effective on August 1, 2024.
• TurningPoint will start accepting prior authorization requests on July 20, 2024, for dates of service on or after August 1, 2024.
• We invite you to join one of these informational webinars free of charge to learn more about the program and our collaboration with TurningPoint. Each webinar will last approximately 30 minutes. For questions about the program, please email providersupport@tpshealth.com.
• Link to Register: https://us06web.zoom.us/meeting/register/tZUsc-6grDMiGtYGmHlyGklX_aCyIEW_vjNr
• Here is the schedule:

Date	Morning
Tuesday 7/9	12:00 p.m. CT
Thursday 7/11	12:00 p.m. CT
Tuesday 7/16	12:00 p.m. CT
Thursday 7/18	12:00 p.m. CT
Tuesday 7/23	12:00 p.m. CT
Thursday 7/25	12:00 p.m. CT
Tuesday 7/30	12:00 p.m. CT
Thursday 8/1	12:00 p.m. CT

• For more details, including a list of the impacted CPT codes, log into Providers.BlueKC.com, and look under Recent News on the home page.

Blue KC Cardiac Surgical Quality and Safety Management Program in Partnership with TurningPoint

Blue KC is introducing a new and innovative Cardiac Surgical Quality and Safety Management Program with TurningPoint Healthcare Solutions, LLC, who will partner with Blue KC to oversee prior authorization requests on Cardiac Surgical Procedures. The program will now be effective as soon as September 1, 2024, and is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for our members receiving Cardiac Surgical Procedures.

• The program will impact the following lines of business, effective as soon as September 1, 2024: Commercial, Blue Medicare Advantage, ACA QHP for Individual/Family and Small Group ACA. Blue KC will adopt TurningPoint’s Medical Polices for all applicable prior authorization requests for all other lines of business, effective as soon as September 1, 2024.
• TurningPoint will start accepting prior authorization requests for Commercial, Blue Medicare Advantage, ACA QHP for Individual/Family and Small Group ACA on August 20, 2024, for dates of service on or after September 1, 2024.
• We invite you to join one of these informational webinars free of charge to learn more about the program and our collaboration with TurningPoint. Each webinar will last approximately 30 minutes. For questions about the program, please email providersupport@tpshealth.com.
• Link to Register: https://us06web.zoom.us/meeting/register/tZAldOutqj4rHtEfENl_kpTZUDkfnpGGMfY0
• Here is the schedule:

Date	Morning
Tuesday 8/6	11:30 a.m. CT
Thursday 8/8	11:30 a.m. CT
Tuesday 8/13	11:30 a.m. CT
Thursday 8/15	11:30 a.m. CT
Tuesday 8/20	11:30 a.m. CT
Thursday 8/22	11:30 a.m. CT
Tuesday 8/27	11:30 a.m. CT
Thursday 8/29	11:30 a.m. CT

• For more details, log into Providers.BlueKC.com, and look under Recent News on the home page.

Code Updates

The codes below will be added to our prior authorization list, effective August 1, 2024. Be sure to use your log-in credentials at Providers.BlueKC.com, and click on our enhanced Prior Authorization function on the home page to view current prior authorization lists.

Code	Description	Effective date	Line of Business
L8682	Implantable neurostimulator radiofrequency receiver	8/1/2024	Commercial
C1764	Event recorder, cardiac (implantable)	8/1/2024	All lines of business
93264	Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional	8/1/2024	MA
J2781	An injection of pegcetacoplan to treat eye disease	8/1/2024	ACA
0587T	Percutaneous implantation or replacement of integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve	8/1/2024	MA

Medical Drug Prior Authorization Removal

To provide for greater efficiencies, Blue KC removed prior authorization requirements for preferred hyaluronan knee injections, effective April 1, 2024. This impacts our Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business.

Code	Drug	Effective date
J7323	Euflexxa	4/1/2024
J7325	Synvisc/One	4/1/2024

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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.

Interim Updates
Effective date – 7/1/2024	ID: 7.01.44 Title: Implantable Cardioverter Defibrillators – Association Policy Policy statements and policy guideline statements for pediatric indications updated. Added extravascular ICD investigational statement
Effective date – 7/1/2024	ID: 2.02.32 Title: Leadless Cardiac Pacemakers – Association Policy Investigational policy statement added to new indications for Aveir DR dual chamber leadless pacemaker.
Effective date – 7/1/2024	ID: 2.01.500 Title: Manipulations and Chiropractic Care – Local Policy Added a statement that Blue KC will not reimburse Chiropractors for these codes: “Health Behavior Assessment and Intervention (HBAI) services described by CPT codes 96156, 96158, 96159, 96164, 96165, 96167, 96168 and any successor codes are billed by clinical social workers, marriage and family therapists (MFTs) and mental health counselors (MHCs), in addition to clinical psychologists.

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Payment Policy Updates

Medically Unlikely Edits (MUE’s)

Blue KC wants to inform you that our new Payment Policy POL-PP-246 Medically Unlikely Edits (MUE’s) will be effective July 1, 2024.

• This payment policy will apply to our Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business.
• In November 2023, Blue KC updated language in the National Correct Coding Initiative (NCCI) Payment Policy under MUE’s to say, “Blue KC may pay units of service in excess of the MUE value if documentation of medical necessity is submitted.”
• Effective July 1, 2024 for Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business, MUE’s with an MUE Adjudication Indicator (MAI) of 3 will be reimbursed up to the allowed amount found on the NCCI MUE table. Units billed in excess of the allowed amount will be denied.
• MUEs assigned an MAI of 3 are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services.
  • For Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business, a formal appeal with documentation clearly explaining the medical necessity for the excess units may be submitted.
  • For our Blue Medicare Advantage line of business, a written inquiry with documentation clearly explaining the medical necessity for the excess units is still appropriate. A statement merely indicating that the patient required additional units will not be accepted.
• To view this new payment policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies. This policy is included in the “New Payment Policies (published within the last 30 days)” section.

Modifiers 59, XE, XS, XP, XU

The new payment policy, POL-PP-247 Modifiers 59, XE, XS, XP and XU, became effective June 1, 2024. These modifiers are important National Correct Coding Initiative procedure to procedure-associated modifiers that physicians and providers often use incorrectly. The following are appropriate uses:

• 59 – Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other services.
• XE – “Separate Encounter, a service that is distinct because it occurred during a separate encounter.” Only use XE to describe separate encounters on the same DOS.
• XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/ structure.”
• XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner.”
• XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.”

For more details, including when not to use these modifiers and rules for documentation, visit Providers.BlueKC.com, and click on Go to Payment Policies. This policy will be included in the “New Payment Policies (published within the last 30 days)” section.

Lyric (Formerly Change Healthcare/ClaimsXten) Editing Rules

Effective June 1, 2024, Blue KC released a new payment policy titled, POL-PP-245 for Lyric (Formerly Change Healthcare/ClaimsXten) Editing Rules. The purpose of this policy is to provide an overview of the processes and procedures involved in our use of Lyric’s (formerly Change Healthcare/ClaimsXten) clinically based claims editing solution.

For policy details and a list of Lyric Editing Rules, visit Providers.BlueKC.com, and click on Go to Payment Policies. This policy will be included in the “New Payment Policies (published within the last 30 days)” section.

Special Investigation Unit Provider Billing Education

Blue KC wants to provide information to providers after seeing a pattern of incorrect billing for the following:

• We have observed Instances of residents and fellows billing for services as Assistant Surgeons. As a reminder, Blue KC’s Payment Policy POL-PP-105 “General Coding and Billing” shows that individuals in training (e.g., students, trainees, interns, residents, fellows) are not considered an assistant and services are not reimbursable, unless otherwise communicated in writing by Blue KC.
• Blue KC and Blue Medicare Advantage continue to receive member complaints that in-network providers are billing members up front for covered services and requiring the members to seek reimbursement from Blue KC/Blue Medicare Advantage directly. This is not appropriate and is a violation of provider contractual agreements. For more information on the correct process, log into Providers.BlueKC.com and click on Resources to find our Provider Reference Guide. Then, scroll down to the Claims, Billing and Remittance section. Once you’re there, look on Page 10 under Member Details to find details on Collection of Member Copayment, Coinsurance, Cost Share or Deductible.

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Blue Medicare Advantage Updates

An Update on Our Medicare Advantage Offerings

We recently announced that Blue KC has made the difficult decision to exit the Medicare Advantage market at the end of 2024.

Like you, we must navigate the significant changes impacting the healthcare industry, and we know we are not alone in our challenges with Medicare Advantage plans. There are heightened regulatory demands and changing provider payment rates, as well as rising market and financial pressures for many in the healthcare industry. Despite our actions to create a more viable, scalable solution for our valued Medicare Advantage members, the required financial investment is not sustainable.

Even though Blue KC is the largest not-for-profit health insurer in Missouri, serving 32 counties including Johnson and Wyandotte in Kansas, our Medicare Advantage membership does not provide the scale required to compete in today’s evolving and challenging market. Exiting Medicare Advantage will allow us to dedicate more time, attention, and resources to developing new products and innovations while continuing to provide affordable, high-quality healthcare coverage to our commercial, group and individual members, including ACA and Medicare Supplement, long into the future.

We will continue to provide high-touch support and uninterrupted access to healthcare for our members currently on a Medicare Advantage plan through 2024 and will support them in a transition to alternative coverage when more information about 2025 options is available.

Medicare Advantage Contracted Provider Post Service Medical Necessity Disputes

A provider medical dispute is the Provider’s dissatisfaction with denial of payment, where a denial has been issued for reasons such as:

Authorization denied

Experimental/investigational

Lack of medical information

If a denial is issued and you proceed with providing the service, the dispute can be filed after the care is completed.

The Provider dispute must be filed in writing within 12 months of the denial date. Provider disputes received after that time will be denied for untimely filing. If the Provider feels that the appeal was filed within the 12-month timeframe, the Provider may submit documentation showing proof of timely filing. Examples of acceptable proof of timely filing include, but are not limited to, registered postal receipt signed by a representative of Blue Medicare Advantage, a similar receipt from other commercial delivery services or a fax submission confirmation. Upon receipt of all required documentation, Blue Medicare Advantage has up to 60 calendar days to review the provider dispute for Medical Necessity and/or compliance to contract policies and to render a decision to reverse or affirm the prior denial. Required documentation includes the Member’s name and subscriber number, date of services and reason the Provider believes the decision should be reversed. Other required information varies based on the type of appeal being requested.

For example, if the Provider is requesting a Medical Necessity review, medical records should be submitted.

The Provider is not allowed to charge Blue Medicare Advantage or the Member for copies of medical records provided for this purpose.

You may submit your Post Service Medical Necessity Provider Dispute to:

Appeals Department Blue KC P.O. Box 417005 Kansas City, MO 64141-7005 OR Fax: 816-278-1920

Reversal of Initial Denial

• If it is determined that the Provider has complied with Blue Medicare Advantage policies and that the disputed services were Medically Necessary, the initial denial will be reversed. The Provider will be notified of this decision in writing. The Provider may file a claim for payment if one has not already been submitted. Any previously denied claim related to the dispute will be reversed and adjusted for payment.

Confirmation of Initial Denial

• If it is determined that the Provider did not comply with Blue Medicare Advantage policies and/or that Medical Necessity was not established, the initial denial will be upheld. The Provider will be notified of this decision in writing.

Provider Responsibilities Related to Member Grievances

Did you know your prompt response to the member grievances process helps meet CMS regulatory timelines?

As you know, Blue Medicare Advantage members may file a grievance (complaint) to us about the quality of service or the quality of care given by our providers. The Blue Medicare Advantage Appeals and Grievance Department investigates the complaint and must resolve the member’s issue, per the CMS regulatory timelines. As a network provider, you must deliver the requested information to us within our requested timeframe, so that we can complete our investigation. Requested documentation may include the following:

• Provide a formal write-up with your insight to the member’s concern(s),
• Member billing statement, or
• Clinical records

This information can be submitted by fax to (877) 549-1748 or email via AppealsGrievances_MA@BlueKC.com. We appreciate your partnership in providing quality care to our members.

Closing the Gap on Transitions of Care – Receipt of Discharge

Transitions of Care has long been a challenging measure for providers to close due to varying requirements of the multiple sub-measures and tight timeframes for compliance. One of the transitions of care most associated with gaps is Transitions of Care – Receipt of Discharge (TRC-RDI). Given the difficulties, we would like to share some best practice guidance that can help eliminate some common challenges.

TRC – RDI 101:
Sub-measure description:	Documentation of receipt of discharge information on the day of discharge or the two following calendar days.
Why it is important:	The receipt of discharge sub measure is designed to help providers initiate medication reconciliation and patient engagement shortly after a qualifying event (acute or non-acute discharge between Jan. 1 – Dec. 1 of the measurement year) to improve health outcomes and prevent readmissions.
How the gap is closed:	The patient’s outpatient medical record must include documentation from the Primary Care Provider (PCP) or ongoing care provider that discharge information is received on the day of discharge or within the two following calendar days. Note: Per NCQA, when using a shared EMR system, documentation of a “received date” in the EMR is not required to meet criteria. Evidence that the information was filed in the EMR and is accessible to the PCP or ongoing care provider on the day of discharge through 2 days after the discharge (3 total days) meets criteria.
Best practice guidance to close the gap:	Date and time stamp when the receipt of the discharge summary was entered in the member’s outpatient medical record. The stamp should include words like “Entered into outpatient medical record” date and time, or “Filed in outpatient medical record” date and time. If you have shared EMR access with multiple health systems, share that with your Provider Engagement Consultant. This information can inform compliance when conducting nonstandard supplemental and HEDIS hybrid medical record review. If a fax is received with a date/time stamp that meets timing guidelines, make a note on the record that it was filed in the outpatient medical record at that time. Just a fax date/time stamp does not meet audit compliance.

The complexities of the TRC – RDI sub-measure can be challenging, but the purpose is something your practice is likely already focused on:

• Preventing avoidable readmissions
• Reducing healthcare costs
• Improving your patients’ experience with their healthcare

Incorporating the best practice guidance above into your daily operations will help you validate the quality of care you are providing, narrow the gap and support your provider incentive Star rating.

V28 Medicare Advantage Risk Adjustment

Did you know we are two-thirds of the way into the V28 Risk Adjustment model changes that CMS outlined? Here is the 10,000-foot overview:

Statistics	Increasing from 86 to 115 HCCS Decreasing from 9,797 to 7,770 ICD-10-CM codes that risk adjust
Impact	IMost HCC numbers will change HCC Removals HCC 47 Protein-Calorie Malnutrition HCC 230 Angina Pectoris HCC 265 Atherosclerosis of Arteries of Extremities with Intermitten Claudication Lysosomal Disorders is given a unique HCC 49 Benign Carcinoid Tumors risk adjust to HCC 22 Malignant Pleural or Pericardial Effusions risk adjust to HCC 17
Providers	Document all coexisting conditions that impact medical decision making Document to the highest level of specificity that reflects the true illness burden of the patient during the encounter

Source: https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/risk-adjustors/2024-model-software/icd-10-mappings

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Pharmacy Policy Updates

New Pharmacy Policy

The following new Blue KC pharmacy policy will be effective July 1, 2024, only impact our Blue Medicare Advantage line of business and require prior authorization:

New Pharmacy Policy – MA
Policy Number	Policy Name	Summary
5.02.576.MA	Trodelvy (Sacituzumab Govitecan) – MA Only	FDA approved for 1) Unresectable Locally Advanced or Metastatic Triple-Negative Breast Cancer; 2) Unresectable Locally Advanced or Metastatic Hormone Receptor (HR)-Positive, Human Epidermal Growth Factor Receptor 2 (HER2)-Negative (IHC 0, IHC 1+ or IHC 2+/ISH-) Breast Cancer; 3) Locally Advanced or Metastatic Urothelial Cancer (mUC)

GLP-1 receptor agonists and DPP-4 inhibitors

Effective July 1, 2024, concurrent use of GLP-1 receptor agonists and DPP-4 inhibitors will be considered duplicate therapy. Medications in these two classes work via similar mechanisms of action, and research has not shown additive effects on glucose lowering when used together. The American Diabetic Association recommends against the simultaneous use due to the increased risk of side effects, such as gastrointestinal disturbances and pancreatitis. Providers should review patient therapy and select one of these agents for glucose control in their patients.

• Examples of GLP-1 RA: Ozempic (semaglutide), Mounjaro (tirzapatide), Trulicity (dulagutide), etc
• Examples of DPP-4 inhibitors: Januvia (sitagliptin), Tradjenta (linagliptin), Janumet (Sitagliptin and Metformin), etc.

Commercial Formulary Updates

We want to let our contracted providers know of updates to the Blue KC Commercial Prescription Drug Lists that will go into effect on July 1, 2024.

Below are the Premium Prescription Drug List updates that will be effective July 1, 2024:

Please Note: These changes ONLY apply to members on the Premium Formulary. Group-specific benefit exceptions may apply.

New Prior Authorization Requirements

Drug Class	Drugs Requiring Prior Authorization
Cancer Agents	Xatmep oral solution
Cardiovascular Agents	Hemangeol oral solution

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Anti-Infective Agents	Uretron D/S tablet	Please talk to your doctor about other option(s).
Dermatological Agents	Rhofade cream	Mirvaso gel
Gastrointestinal Agents	Debacterol solution	Please talk to your doctor about other option(s).
Muscle Relaxants	Fleqsuvy, baclofen suspension	baclofen tablet
Nonsteroidal Anti-Inflammatory Agents (NSAIDs)	EC-Naproxen tablet	naproxen tablet
	tolmetin sodium capsule	celecoxib, diclofenac tablet, etodolac, ibuprofen, meloxicam tablet, indomethacin capsule
	tolmetin sodium tablet
Ophthalmic Agents	Prolensa	ketorolac op sol 0.5%, flurbiprofen op sol 0.03%, diclofenac op sol 0.1%
Renal and Genitourinary Agents	Oracit solution	oral citrate solution
	Tricitrates solution	Please talk to your doctor about other option(s).
	Phospha 250 tablet	wes-phos 250 neutral tablet, phosphorous tablet
	K Citrate solution	Please talk to your doctor about other option(s).
Upper Respiratory Combinations	promethazine & phenylephrine syrup	covered generic cough and cold products
	promethazine-phenylephrine-codeine syrup

Tier Changes Affecting Member Copayment

Medications moving from Tier 3 to Tier 2

Mirvaso gel

New Excluded Drugs with Covered Generic Equivalents

Actonel tablet	Agrylin capsule	Alphagan P solution	Avalide tablet
Cardizem tablet	Cardura tablet	Diflucan tablet	EC-Naprosyn tablet
Effient tablet	Fosrenol chew	Gastrocrom concentrate	Inspra tablet
Jalyn capsule	Mestinon tablet	Namenda tablet	Nebusal nebulizer 3%
Spiriva Handihaler	Urocit-K tablet	Urso 250 tablet	Urso Forte tablet
Vancocin capsule

New Excluded Medications with Over-the-Counter (OTC) Alternatives

The following drugs are now excluded but alternatives are available for members to purchase out of pocket, over the counter.

Drug Class	Excluded Medications	Alternative
Antifungal Agents	Mycozyl AL 1% external	OTC tolnaftate
Nonsteroidal Anti-inflammatory (NSAID) Agents	Topical diclofenac (cream, gel, solution)	Use OTC products containing an active ingredient such as diclofenac. Consult your pharmacist or physician about the appropriate option.
Dermatological Agents	adapalene	Use OTC products containing an active ingredient such as adapalene. Consult your pharmacist or physician about the appropriate option.
	Tazorac, tazarotene
	tretinoin, tretinoin microsphere gel
Ophthalmic Agents	alcaftadine	Use OTC ophthalmic products containing an active ingredient such as olopatadine, ketotifen, or alcaftadine. Consult your pharmacist or physician about the appropriate option.
	azelastine HCL
	bepotastine besilate
	cetirizine HCL
	olopatadine HCL
	ketotifen fumarate

Below are the Select Prescription Drug List updates that are effective July 1, 2024:

Please Note: These changes only apply to members on the Select formulary. Group-specific benefit exceptions may apply.

New Step Therapy Requirements

Members must try preferred alternatives before other drugs will be covered.

Drug Class	Drugs Requiring a Trial of Alternative(s)	Preferred Alternatives (Try First)
Dermatological Agents	Rhofade cream	Mirvaso gel
Ophthalmic Agents	Prolensa	One of the following: ketorolac op sol 0.5%, flurbiprofen op sol 0.03%, diclofenac op sol 0.1%
Respiratory Agents	Spiriva Handihaler	tiotropium bromide inhal cap

New Prior Authorization Requirements

Drug Class	Drugs Requiring Prior Authorization
Cardiovascular Agents	Hemangeol solution
Cancer Agent	Xatmep solution

Tier Changes Affecting Member Copayment

Please Note: The following tables report the impact of formulary changes to the most utilized medications.

Medications Moving to a Lower Tier
Mirvaso gel
Medications Moving to a Higher Tier
Alphagan P	Prolensa	Spiriva

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Antiandrogens	Yonsa tablet
Antifungal Agents	Brexafemme tab	fluconazole
Anti-Infective Agents	Uretron D/S tablet	Please talk to your doctor about other option(s).
Antiretroviral Agents	Vemlidy tab	entecavir, tenofovir disoproxil
Blood Glucose Monitoring	Tempo Welcome Kit	Ascencia (contour, contour next) blood glucose monitor
Cardiovascular Agents	Camzyos capsule	carvedilol, metoprolol er, diltiazem
	Inpefa tablet	Farxiga, Jardiance

Drug Class	Excluded Medications	Covered Alternative
Endocrine and Metabolic Agents	Isturisa tablet	ketoconazole tablet
	Mycapssa capsule	octreotide acetate injection
	Palynziq injection	sapropterin powder/tablet
Gastrointestinal Agents	Debacterol solution	Please talk to your doctor about other option(s).
	Relistor tablet	Symproic
Hematological Agents	Oxbryta tablet	hydroxyurea
Immunologic Agents	Ponvory tablet	glatiramer, glatopa, dimethyl fumarate, fingolimod
	Rezurock tablet	Jakafi, Imbruvica
	Tascenso ODT	Please talk to your doctor about other option(s).
Muscle Relaxants	baclofen suspension	baclofen tablet
Nonsteroidal Anti-Inflammatory Agents (NSAIDs)	EC-Naproxen tablet	naproxen tablet
	tolmetin sodium	celecoxib, diclofenac tablet, etodolac, ibuprofen, meloxicam tablet, indomethacin capsule
Ophthalmic Agents	Cequa solution 0.09%	Restasis, Xiidra
	Iyuzeh drops 0.005%	latanoprost ophthalmic solution
Renal and Genitourinary Agents	Oracit solution	oral citrate solution
	Tricitrates solution	Please talk to your doctor about other option(s).
	Phospha 250 tablet	wes-phos 250 neutral tablet, phosphorous tablet
	K Citrate solution	Please talk to your doctor about other option(s).
Respiratory Agents	Airduo Digihaler	Advair HFA, Breo Ellipta, Symbicort
	Airduo Respiclick
	Tudorza Pressair	Spiriva
Upper Respiratory Combinations	promethazine & phenylephrine syrup	covered generic cough and cold products

New Excluded Drugs with Covered Generic Equivalents

Actonel tablet	Agrylin capsule	Avalide tablet	Cardizem tablet
Cardura tablet	Diflucan tablet	EC-Naprosyn tablet	Effient tablet
Fleqsuvy suspension	Fosrenol chew	Gastrocrom concentrate	Inspra tablet
Jalyn capsule	Mestinon tablet	Namenda tablet	Nebusal nebulizer 3%
Urocit-K tablet	Urso 250 tablet	Urso Forte tablet	Vancocin capsule

New Excluded Medications with Over-the-Counter (OTC) Alternatives

The following drugs are now excluded but alternatives are available for members to purchase out of pocket, over the counter.

Drug Class	Excluded Medications	Alternative
Antifungal Agents	Mycozyl AL 1% external	OTC tolnaftate
Nonsteroidal Anti-inflammatory (NSAID) Agents	Topical diclofenac (cream, gel, solution)	Use OTC products containing an active ingredient such as diclofenac. Consult your pharmacist or physician about the appropriate option.
Dermatological Agents	adapalene	Use OTC products containing an active ingredient such as adapalene. Consult your pharmacist or physician about the appropriate option.
	Tazorac, tazarotene
	tretinoin, tretinoin microsphere gel
Ophthalmic Agents	alcaftadine	Use OTC ophthalmic products containing an active ingredient such as olopatadine, ketotifen, or alcaftadine. Consult your pharmacist or physician about the appropriate option.
	azelastine HCL
	bepotastine besilate
	cetirizine HCL
	olopatadine HCL
	ketotifen fumarate

Below are the Essential Health Benefits (EHBs) Prescription Drug List updates that will be effective July 1, 2024:

Please Note: These changes ONLY apply to members on the EHB Formulary. Group-specific benefit exceptions may apply.

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Anticonvulsants	Celontin cap	methsuximide cap
Blood Modifiers	Mozobil	plerixafor injection
Metabolic Agents	Orfadin cap	nitisinone cap
Ophthalmic Agents	Alphagan P	brimonidine ophthalmic solution 0.1%
	Prolensa	ketorolac op sol 0.5%, flurbiprofen op sol 0.03%, diclofenac op sol 0.1%, bromfenac op sol 0.07%

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Provider Education

Timely Filing Claim Adjustments

Blue KC is pleased to provide helpful information for timely filing. We want to make sure you know claim adjustments must be made within 12 months of the original paid date for claims previously processed by Blue KC. This includes corrected claims, which also must be submitted within 12 months of the claim’s original process date.

For an overview and other steps to follow for timely filing, please review our Provider Reference Guide at this link: https://Providers.BlueKC.com/Content/PDFs/PRG/ClaimsBillingRemittance.pdf. The timely filing section is on page 5.

Guidelines for Corrected Electronic Professional Claims (837P)

Blue KC expects the original claim submission to be accurate and fully reflect all information gathered during the initial patient encounter. However, when there are circumstances that require a corrected claim, please note the following requirements for submitting a corrected electronic claim.

All of the following information (data elements) must be provided on the electronic claim:

Name of Data Element	837P Loop and Data Element	Data Element Information
Claim Frequency Type Code	2300 / CLM05 - 3	7 (Replacement of a Prior Claim)
Payer Claim Control Number Qualifier (Original Reference Number Qualifier)	2300 / REF01	F8
Payer Claim Control Number (Original Claim Number)	2300 / REF02	The original BCBSKC assigned claim number.
Claim Note Reference Code	2300 / NTE01	ADD (Additional Information)
Claim Note Text	2300 / NTE02	Free-form text field (80 characters) to provide a description of correction. Entering “Corrected Claim” is not acceptable.

Please use the following listing to determine if you can submit a corrected electronic claim. If a corrected claim cannot be submitted, please submit your corrected claim request on a claim inquiry form.

Submit a corrected electronic claim for the following:	Do Not submit a corrected electronic claim for the following (use a claim inquiry form)
COB – Original claim was denied for other carrier info. Send a corrected claim with the necessary COB data elements.	Claims that have been denied for medical necessity.
Changes related to date of service, CPT, HCPCS, DX code.	Claims that have been denied for investigational or experimental services.
The original claim was denied for additional information, such as – NDC code, CPT or HCPCS description (NOC code). Send corrected claim with full code description in the Claim Note Text.	Claims with services that have been bundled or denied inclusive of another service.
Original claim for DME, Clinical Lab, or Specialty Pharmacy denied for no referring physician. Send corrected claim with the referring physician info.	Claims that have been denied for lack of information request for additional clinical documentation (office notes, surgical notes, reports, etc).

How will Blue KC handle my Corrected Electronic Professional Claim (837P)?

Blue KC Line of Business	Original Claim	Corrected Claim
Regular (local) Business	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on the same remittance advice.
Federal Employee (FEP)	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on the same remittance advice.
BlueCard (ITS)	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on different remittance advices. Because these claims are going to the members’ Home Plan, please allow 30 days for the corrected claim to process.

CAQH Attestation

Effective January 1, 2022, the Consolidated Appropriations Act (CAA) requires group health plans and issuers offering group and individual health plans to establish a verification process to confirm directory information at least every 90 days.

• Delegated Providers attest through monthly file and quarterly roster submission.
• Non-Delegated Providers must attest quarterly through CAQH Proview.

CMS and NCQA are among those who require providers to attest to their data in CAQH every 90 days. Blue KC enforces this policy, as well. Lack of quarterly attestation will result in the provider being suppressed from the Blue KC Directory.

Provider Updates and Credentialing Form Requirements

Blue KC is seeing a pattern of providers using old forms for provider updates and credentialing. As reported in previous Blue KC provider publications, we have new versions of these forms on our Provider Portal, so we will no longer be accepting old forms.

We have an easier-to-use Provider Updates Form and six different form options to meet your credentialing needs, from initial credentialing to revalidation. You must be able to log into the Provider Portal and have a Portal account to access these forms. We make it easy to create an account! Click here to learn how.

To find these enhanced forms, log into Providers.BlueKC.com, click on Forms under Quick Links on the home page and look under the Provider Services header.

Note: For provider updates and credentialing, Blue KC will no longer accept faxed or email requests from contracted providers due to the need for all required data elements to be submitted. (The OON is not an online form and an exception to this.)

Reminder: Blue KC Customer Service Hours for Providers

As a reminder, Blue KC’s customer service hours for providers are 8 a.m. – 6 p.m. CT, Monday – Friday. If you need assistance outside of these hours, you can visit our website at www.Providers.BlueKC.com where you can “Contact Us” anytime or call the numbers listed above and request a callback for the next business day.

Lines of Business	Hours of Operation
Commercial, MA, ACA IFP, Medicare Supplement	8 a.m. – 6 p.m. CT

SQM Group Recognizes Blue KC for World-Class Customer Service

In recognition of its commitment to exemplary customer service, Blue Cross and Blue Shield of Kansas City (Blue KC) was recently honored with multiple 2024 Call Center Customer Service Industry Awards of Excellence from Service Quality Management (SQM), a survey vendor that benchmarks over 500 customer service centers across North America.

Blue KC was recognized in three categories for Customer Experience Excellence by SQM:

• Call Center of the Year Award Finalist
  • Criteria includes companies with the highest combined First Call Resolution (FCR) and Employee Experience (EX) rating.
• Call Center World Class FCR Certification
  • Based on 80% or higher of customers getting their contact resolved on the first call to the call center (FCR) for 3 consecutive months or more.
• World Class Employee Experience Award
  • Based on 50% or higher of employees who rate their overall experience of working in the call center as very satisfied (top box rating).

Since 1996, SQM has been a Customer Service First Call Resolution (FCR) Expert for measuring, tracking, and improving FCR. Conducting over 25,000 surveys annually with employees who work in call centers, SQM also boasts one of the largest customer and employee survey databases in North America.

“One of the reasons Blue KC earns the trust of our members is by providing the highest quality customer experience possible,” said Gratia Carver, Vice President and Chief Experience Officer. “Our service team is one of the best in the industry, and this recognition from SQM reflects that. We take the time and steps necessary to ensure our employees have everything they need to provide the high-end service our customers deserve and expect. It’s always gratifying to be recognized and we thank SQM for honoring us.”

Based on customer and employee studies, SQM awards excellence in FCR, customer satisfaction, and employee satisfaction for the call center industry. SQM’s Call Center Customer Service Industry Awards of Excellence are considered North America’s most prestigious and sought-after customer service industry awards.

To learn more about Blue KC’s commitment to member satisfaction, please visit BlueKC.com/consumer/blue-kc/about.

Vaccine Education

Providers are essential to the improvement of our members’ health through preventative health care services. These services include immunizations, as well as various healthcare screenings, which often include lab work. It is important for the members’ overall health to have these services in a timely fashion.

We want to help ensure that children have a healthy start by getting the recommended immunizations. Providing education to the parents on the importance of the vaccines in the first two years of life helps in overcoming vaccine hesitancy.

Childhood immunizations include a specific set of vaccines given on or prior to the member’s 2nd birthday. The following must be completed before the child 2nd birthday: four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines.

The Adolescent population requires specific immunizations on or prior to the member’s 13th birthday. HPV is one of several immunizations given to our adolescent members. The immunization can be given in two doses, 146 days apart. Members often either have no doses or just one dose of the vaccine. Immunizations can be given during well child visits.

We want to help dispel any myths regarding HPV vaccine by providing staff and members with the education on the importance of HPV vaccine for the prevention of cancers and cite the recommended guidelines. Making members aware of extended hours, vaccination appointments only and weekend appointments could help with the timeliness of these services.

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, please visit: https://Providers.BlueKC.com/Content/PDFs/PRG/BlueKCBasics.pdf.
• Utilization Management Policies: Medical and Pharmacy review criteria, along with Medical policies, are available at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf 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 at https://Providers.BlueKC.com. In addition, explanation on limits/quotas, the steps required to initiate an exception request, and the Blue KC process for generic substitution, therapeutic interchange and step therapy protocols are accessible by logging into the provider portal at https://Providers.BlueKC.com or by contacting Pharmacy Services at 816-395-2176.
• Special Notice – How Utilization Management 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. Blue KC does not reward its Utilization Management (UM) staff for issuing denial of coverage decisions. There are no financial incentives offered to UM staff to make decisions that would encourage underutilization of services. Learn more at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.
• Complex Case Management: Information on our Complex Case Management Program, including referral criteria and how to refer patients to the Program, can be found at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.

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Health Equity

Blue KC Partners with Black Health Care Coalition

In 2024, Blue KC is partnering with the Black Health Care Coalition (BHCC) to throw Community Baby Showers for expecting Moms and Dads!

At events in April and June, parents were able to get important information about maternal health, make connections for needed resources and education, pose for a maternity photo shoot, play games and stock up on diapers, food and gifts! Blue KC team members were there with our Blue To You Van to hand out baby wipes and offer free blood pressure screenings.

There will be one more Community Baby Shower on November 2 at the Kansas City Health Department from 10 a.m. to 1 p.m. For more information about BHCC, click here.

Health of America Report: Postpartum Birthing Complications Disproportionately Affect Black Patients

New data from the Blue Cross Blue Shield Association’s latest Health of America report finds that as many as one-third of birth complications occur during the postpartum period, or six weeks post-delivery.

• There are clear racial disparities in the prevalence of these severe maternal morbidity (SMM) events, with rates 87% higher among Black patients compared to white patients.
• Six health events account for over 75% of SMM events: sepsis, eclampsia, acute renal failure, thrombotic embolism, acute respiratory distress syndrome and acute heart failure.
• Click here to learn more.

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Community Investment

Blue KC, Children’s Mercy Kansas City and Center School District Tackle Youth Mental Health Crisis

In January 2024, Blue KC and Children’s Mercy Kansas City launched a three-year early intervention pilot program with the Center School District in Kansas City, MO to tackle the mental health crisis among school-aged children. The pilot program, in part, will incorporate restorative practice training with the expertise of RestorED.

The goals of the initiative are to proactively support the social and emotional needs of students and teachers with evidence-based behavioral health education and to improve student engagement, attendance, and performance, while simultaneously reducing the incidents of disruptive behavior that often lead to suspension and expulsion. To learn more about the initiative, click here.

First-ever Teal Talks a Success

Blue KC and the Kansas City Current hosted the first “Teal Talks” on May 21 at CPKC Stadium, welcoming more than 50 high school female soccer players from Kansas City metro schools.

The student athletes participated in a soccer scrimmage on the pitch at CPKC Stadium, prior to taking part in a panel discussion of behavioral health experts, sports psychologists and Current player Desiree Scott. The message to the students centered around the experience of a female athlete regarding competition, resiliency and mental health.

"Teal Talks” is part of “Sideline the Stigma”, the behavioral health initiative developed in partnership with Blue KC and the KC Current. The initiative focuses on promoting actionable and practical resources to remove the stigma surrounding mental health and giving support to all Kansas Citians.

There are plans to conduct a second Teal Talks later this season. For more information on Sideline the Stigma, click here.

Blue KC Sponsored Kansas City Community Gardens Annual “Tomato Days” Event

Blue KC was proud to partner recently with Kansas City Community Gardens (KCCG) at its annual Tomato Days plant sale, which provided hundreds of low-income KCCG members with plants that will help them grow their own healthy foods in home and community gardens. Blue KC has been a long-time supporter of Kansas City Community Gardens’ efforts of increasing access to nutritious foods in underserved neighborhoods through our Well-Stocked initiative.

We Are Kansas City

At Blue KC, we take pride in the fact we’ve been part of the fabric of the Kansas City community for over 85 years. We are Kansas City’s local health insurance company, and when you call our Provider Customer Service team, you’re going to connect with someone who could be your neighbor.

Our employees are invested in Kansas City, and we’re proud of our award-winning team that works daily to provide affordable access to healthcare and improve the health of our members. We’re also proud to recruit and cultivate homegrown talent who share their time and talents to strengthen our community.

Click here or the image above to learn more about the remarkable local volunteer efforts from one of our team members who was born and raised in Wyandotte County. In the coming months, we’ll be shining the spotlight on other employees who are sharing their time and talents to strengthen the community. We’re excited to have the opportunity to introduce you to your local neighbors at Blue KC!

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Provider Portal Enhancements

Blue KC’s Provider Portal is now better than ever! Our powerful digital tool for providers can be accessed 24/7 with the click of a button!

Provider Portal Features include:

• Search and review claims
• Submit and view electronic prior authorizations
• Look up member eligibility and benefits
• Access Medical and Payment Policies
• See provider remittances
• View Provider Reference Guides
• Check out recent news updates
• Read BlueSpeak provider e-Newsletter
• Find helpful provider forms
• Use dental resources
• And so much more!

Blue KC is proud of recent enhancements that were made to the Portal.

A new-look home page gives you one- to two-click access to core health insurance functions, including member eligibility and benefits, prior authorization, claims inquiry and remittances.

The new enhancements provide quicker account registration and a much easier prior authorization experience. To learn more, click here to view a written summary and video about each enhancement.

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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, 866-508-7140 for Blue Medicare Advantage line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

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