In addition to the Cotiviti announcement for data mining shared in the July 2026 BlueSpeak Newsletter, Blue KC will also introduce Post-Payment Clinical Claim Validation (CCV) reviews with Cotiviti. Clinical Chart Validations with Cotiviti will begin November 1, 2026.

• CCV reviews are conducted to ensure proper billing. These reviews will require a copy of the medical records and will be requested by Cotiviti, if Blue KC has not already received the medical records.
• Cotiviti’s staff includes registered nurses and medical and claims experts with varying expertise, including, but not limited to:
  • Coding
  • Claims operations
  • Quality
• Cotiviti works with health plans across the United States to conduct payment accuracy and claim validation reviews.
• The reviews are based on documentation and coding accuracy and are not based on medical necessity review.

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Prior Authorization Updates

Code additions

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

The following codes will be added to our prior authorization list, effective October 1, 2026.

Code	Description	Effective Date	Lines of Business Impacted
58674	Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency	10/1/2026	ACA (already impacts Commercial)

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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. Note: This newsletter is intended to highlight new and updated policies but is not a comprehensive list of all policies or updates.

Payment Policies Featured in this Section

Facility Observation G0378, G0379

Inpatient Readmissions

MOHs Micrographic Surgery

Office Facility Fees

Revenue Code 0710 Recovery Room

Facility G0378, G0379 Payment Policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-258	Facility Observation G0378, G0379	9/1/2026	9/1/2026	View our Facility Observation G0378, G0379 Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates added

• Effective September 1, 2026, Facility G0378, G0379 Payment Policy will now be called Observation Care Payment Policy.
• To improve billing consistency and clarify application of observation services, the policy now includes additional examples of circumstances in which observation is considered integral to another reimbursable service and is not separately reimbursed. These examples are intended to support accurate coding and billing and are not an all-inclusive list.
  • Standing orders following outpatient surgery
  • No professional provider orders for observation services
  • Extended observation following a procedure
  • Services provided concurrently with chemotherapy
  • Inpatient discharged to outpatient observation status
  • Outpatient blood administration (e.g., blood transfusion)
  • Routine preparation prior to, and recovery after, diagnostic testing
  • Awaiting transfer to another facility

Inpatient Readmissions Payment Policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-239	Inpatient Readmissions	11/1/2026	11/1/2026	View our Inpatient Readmissions Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates added

• Effective November 1, 2026, for the Inpatient Readmissions Payment Policy (formerly 30 Day Readmissions Payment Policy), Blue KC will not provide separate reimbursement to acute care hospitals when a patient is readmitted within 15 calendar days of discharge to the same health system for a related condition or admission.
• When a qualifying readmission occurs within 15 days of a prior inpatient discharge, the admissions will be combined and reimbursed as a single payment in accordance with the hospital's contractual agreement.
• Related readmissions include, but are not limited to:
  • Readmissions for the same or a closely related condition, diagnosis, or procedure as the initial admission.
  • Readmissions resulting from an infection, complication, or adverse event associated with the original hospitalization or post-discharge care.
  • Readmissions involving a condition or procedure that indicates a failed surgical or medical intervention.
  • Acute exacerbations or decompensation of a coexisting chronic condition that may be related to care provided during the initial admission or the post-discharge period.
  • Readmissions associated with clinical instability at the time of discharge, including premature discharge, inadequate care coordination, or insufficient discharge planning and follow-up.
• This policy is intended to encourage effective care transitions, appropriate discharge planning, and high-quality patient outcomes while reducing avoidable readmissions.

MOHs Micrographic Surgery Payment Policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-118	MOHs Micrographic Surgery	9/1/2026	9/1/2026	View our MOHs Micrographic Surgery Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates added

• The policy previously included the statement, "All surgical procedures performed in the same operative session should be reported on the same claim."
• This language has been removed from the policy, and providers are now allowed to submit procedures on separate claims, even if they are performed in the same operative session.

Office Facility Fees Payment Policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Policy Number	Policy Name	Effective Date	Full Policy Location
POL-PP-127	Office Facility Fees	3/1/2020	View our Office Facility Fees Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Reminder

• As a reminder, Blue KC defines an office place of service (POS) as a location outside of a hospital or facility where a professional provider or private practice may own equipment, employ staff, and/or be responsible for overhead expenses.
• In addition, Blue KC defines an office setting as one that is located within a hospital or facility, a professional building attached to and owned by a hospital or facility, or an offsite professional building owned by a hospital or facility when one or more of the following conditions is present:
  • The office space is leased by, or subject to an agreement between, a professional provider/private practice operating under a separate Tax Identification Number (TIN) or National Provider Identifier (NPI) and the hospital or facility.
  • The office is located in a separately identifiable area of the hospital or facility that is used exclusively by the professional provider or private practice, regardless of state licensing or certification designations (for example, orthopedic, pediatric, or specialty clinics).
  • Equipment is located in leased space within the hospital or facility, and services such as radiology or electrocardiograms are performed in that space, regardless of equipment ownership.
  • The location is a freestanding or off-campus site owned by a hospital, facility, or health system that contains separate office suites or physician practice space.
• Under Office Facility Fees POL-PP-127 Payment Policy, certain clinic and freestanding clinic revenue codes are considered not eligible for separate reimbursement when billed as facility fees in an office setting. These include, but are not limited to 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0523, 0526, and 0529. Office facility revenue codes should never be reported on an inpatient claim.
• Additionally, these office/freestanding clinic revenue codes are intended to represent services rendered in an office setting and should not be reported on inpatient facility claims. When billed on an inpatient claim, the revenue codes are not consistent with the place of service and facility type represented by an inpatient admission and may be subject to denial in accordance with Blue KC reimbursement policy.

Revenue Code 0710 Recovery Room Payment Policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-330	Revenue Code 0710 Recovery Room	10/1/2026	10/1/2026	View our Revenue Code 0710 Recovery Room Payment Policy Visit our Payment Policies page Go to Providers.BlueKC.com, click on “Go to Payment Policies”

Updates added

• This policy applies to outpatient surgical procedures submitted by facilities not contracted to use CMS reimbursement methodology.
• The recovery room, also called the Post-Anesthesia Care Unit (PACU), is where a patient goes right after surgery to wake up from anesthesia and where specially trained nurses monitor vital signs (breathing, heart rate, blood pressure) as the patient stabilizes. They may receive pain or nausea medication and gradually become alert before being moved to a hospital room or discharged home.
• 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.
• Revenue code 0710 is only allowed on the day of surgery/procedure.
• Revenue code 0710 (Recovery Room) must be reported in conjunction with a valid anesthesia revenue code 037X. When revenue code 037X is not billed with revenue code 0710, the claim will be denied due to incomplete or incorrect data.

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Medical Policy Updates

New policy

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

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).

The Blue KC Medical Policy encompasses internally developed 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.

Note: This newsletter is intended to highlight new and updated policies but is not a comprehensive list of all policies or updates.

Effective date – 9/1/2026

ID: S-561-001 Title: Histotripsy – New Policy Histotripsy of recurrent and metastatic liver tumors may be considered medically necessary in individuals when ALL of the following are met: Tumor size is less than 4cm Have three or fewer liver tumors to be treated The tumor is in a favorable location Histotripsy performed not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

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Pharmacy Policy Updates

New pharmacy policies

Below are new Blue KC pharmacy policies effective September 1, 2026, for medications that already require prior authorization. Note: This newsletter is intended to highlight new and updated policies but is not a comprehensive list of all policies or updates.

New Pharmacy Policies
Policy Number	Policy Name	Summary
5.02.697	Yartemlea (narsoplimab-wuug)	FDA approved for Hematopoietic cell transplant-associated thrombotic microangiopathy (TA-TMA); IV; Medical-Rx benefit

Pharmacy policies with changes

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Below are Blue KC pharmacy policies with updates effective September 1, 2026, for medications that already require prior authorization. Note: This newsletter is intended to highlight new and updated policies but is not a comprehensive list of all policies or updates.

Pharmacy Policies with Changes
Policy Number	Policy Name	Summary
5.02.552	Fasenra – ACA QHP Only	Added indications for Eosinophilic Granulomatosis with Polyangiitis & Hypereosinophilic Syndrome
5.01.667	Tzield (teplizumab-mzwv)	Expanded age from >8 down to >1 years

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Provider Education

Maternity billing services updates

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Blue KC is updating our maternity services billing processes to align with new American Medical Association (AMA) requirements for all lines of business. The AMA has revised coding for global maternity billing, with updates effective January 1, 2027.

• The AMA has revised maternity coding and eliminated the use of traditional global maternity billing codes, effective January 1, 2027.
• This is an industry-wide AMA coding change that affects the way maternity services are reported.
• The transition will result in providers submitting claims throughout the pregnancy rather than waiting until delivery to submit a global maternity claim.
  • This change is viewed as a back-end change in how providers submit claims to Blue KC; moving away from one bundled claim to individual claims for the services performed.
• To support this transition, we encourage providers to begin making changes to the way maternity services are billed to support accurate reimbursement of services performed on or after January 1, 2027.
  • This includes providers making changes to the way they bill using E/M codes for prenatal visits starting September 1, 2026, for anyone expected to deliver on or after January 1, 2027.
• Providers should evaluate their clinical, billing and EHR workflows now to prepare for a transition from global maternity billing to encounter-based billing.
• Blue KC encourages providers to review guidance published by the American College of Obstetricians & Gynecologists (ACOG) and the AMA.

CPT Code 96379 added for 837P and 837I claims

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Blue KC requires the use of National Drug Codes (NDCs) and NDC units on all Professional (837P) and Outpatient Institutional (837I) claims.

• Effective November 1, 2026, for Therapeutic, Prophylactic or Diagnostic injection or infusion (96379), claims must be submitted with NDC and NDC units of measure in the 2410 loop of the 837P and the 837I.
• All drug-related J-codes, as well as Synagis (90378) and Lutathera (A9513), are already in effect, which was announced in a previous communication.
• The NDC submitted must be the actual NDC noted on the drug package or container.
• The appropriate HCPCS code and units are also required.
• The NDC is usually found on the drug label or medication’s outer packaging.
• When the NDC appears on both, it is recommended to use the NDC on the individual product being dispensed.
• For unclassified J codes and other HCPCS/CPT codes that do not describe the dosage per HCPCS/CPT code unit, include the NDC, number of NDC units and HIPAA standard NDC unit of measure qualifier. The NDC units and NDC units qualifier must represent the dosage for the charge.
• The data elements below must be provided on the electronic claim.
• Claims that do not comply with the parameters stated below will be rejected by Blue KC’s clearinghouse.

Name of Data Element	837P or 837I Loop /Data Element	Data Element Information
Product/Service ID Qualifier	2410 / LIN02	N4
Product/Service ID	2410 / LIN03	NDC (11 digit with no hyphens)
Quantity	2410 / CTP04	NDC Unit Count
Unit or Basis of Measure Code	2410 / CTP05	Unit of Measure Examples: F2 - International Unit GR - Gram ME - Milligram ML - Milliliter UN - Unit

Phothera to be an in-network chronic skin treatment option, effective September 1, 2026

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Effective September 1, 2026, Phothera will be a new in-network Durable Medical Equipment option for Blue KC members and follow MCG Guideline A-0255.

• Phothera is an FDA-cleared narrowband home phototherapy device for treating chronic skin conditions
• Chronic skin conditions the device can be used to treat include:
  • Atopic dermatitis (eczema)
  • Cutaneous T-cell lymphoma
  • Vitiligo
  • Psoriasis
  • Chronic itching (pruritus)

The following codes will be used for billing Phothera, effective September 1, 2026:

Code	Description
E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4-foot panel
E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6-foot panel
E0694	Ultraviolet multidirectional light therapy system in 6-foot cabinet, includes bulbs/lamps, timer and eye protection

Why maintaining accurate taxonomy in NPPES matters

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Maintaining an accurate taxonomy code within the National Plan and Provider Enumeration System (NPPES) is critical to ensuring proper claim processing, payment accuracy, and provider alignment within the network.

• Blue KC relies on the taxonomy associated with each provider’s NPI in NPPES as the primary source of truth when determining provider specialty and validating claims.
• When a provider’s taxonomy is outdated or does not reflect their current scope of practice, it can result in:
  • Claim rejections or denials due to NPI/taxonomy mismatches
  • Payment delays while discrepancies are investigated and resolved
  • Inaccurate reimbursement based on inaccurate specialty classification
• Additionally, taxonomy drives how providers are configured in payer systems, including whether they are recognized as primary care or specialty providers.
• When this information is inaccurate, it can impact claim processing, provider program eligibility, member attribution for value-based programs, reporting, and other administrative processes.
• Provider Action
  • Providers should routinely review their taxonomy information in NPPES and update it whenever there is a change in specialty, subspeciality, role, or scope of practice. Maintaining accurate information helps support efficient claim processing, appropriate reimbursement, and accurate provider records.
• FAQ: Taxonomy Updates
  • Q: Where do I update my taxonomy?
    • A: Taxonomy updates must be made directly in the NPPES system associated with your NPI. https://npiregistry.cms.hhs.gov/search
  • Q: How often should taxonomy be reviewed?
    • A: Providers should review their taxonomy anytime there is a change in specialty, role, or practice setting, and periodically to ensure accuracy.
  • Q: How does taxonomy impact claims?
    • A: Blue KC uses taxonomy to validate provider specialty. Mismatches between claim submission and NPPES can result in claim rejection or delays.
  • Q: Does updating taxonomy in NPPES automatically update payer systems?
    • A: Providers should update their taxonomy directly in NPPES and notify Blue KC of any specialty or scope-of-practice changes to help ensure provider records remain accurate across administrative and operational processes.
  • Q: What happens if my taxonomy is incorrect?
    • A: Incorrect taxonomy can lead to claim denials, delayed payment, or incorrect reimbursement until the discrepancy is resolved.

Working together to helping Blue KC members stay updated on vaccines

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Blue KC is committed to helping members understand the importance of vaccines and how staying current helps protect both themselves and their families.

• If the Blue KC member receives a vaccine at a health department or another location outside of the primary care provider’s office, we are asking to please be sure to share the vaccination records with their primary care physician for childhood immunizations and adult immunizations.
• This ensures the care team has the most accurate and up-to-date information in the member medical record.
• By keeping the records coordinated:
  • We can avoid receiving duplicate vaccinations
  • The care team can better track which vaccines the member has already received
  • The provider can identify any vaccines the member may still need
• Working together helps ensure the members receive the right care at the right time.

Attention referring providers: How to submit lab orders to avoid denials

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Blue KC is experiencing an increase in clinical edit denials for independent laboratory claims. This guidance outlines the causes and provides clear steps for referring providers to prevent denials and ensure proper reimbursement.

Why are denials increasing?

Clinical edit denials are primarily occurring due to: Missing, invalid, or incorrect modifiers submitted on claims Primary diagnosis codes that do not support medical necessity Important: Independent laboratories cannot change or correct diagnosis codes. They depend entirely on the referring provider to submit complete and accurate clinical information when the test is ordered. Because of this: Labs cannot resolve denials without provider involvement Claims may go unpaid for services already performed

What providers must do

To prevent denials, referring providers must follow these steps: 1. Follow Blue KC Laboratory Medical Policies a. Adhere to all coverage criteria, medical necessity requirements, and coding guidelines for lab services 2. Submit Accurate Diagnosis Codes a. Before ordering lab tests: i. Ensure diagnosis codes are complete and accurate ii. Confirm codes support medical necessity iii. Verify alignment with Blue KC medical policies 3. Educate Members on Coverage a. If a test is not covered: i. Inform the member before services are performed ii. Explain any potential out-of-pocket costs Key Reminder Independent laboratories rely entirely on referring providers for correct clinical and coding information. Errors at the time of order entry can lead to denials that only the provider can resolve.

Free documentation & coding webinar in September

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Join us for the September 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:

September 22 & 24 7:30 am & 11:30 am CT

Streamline Documentation and Coding for Genitourinary Conditions

Explore documentation and coding for Genitourinary conditions, such as Nephritis, Nephropathy, Kidney Infections and Chronic Kidney Disease.

New Provider Portal login page

LINE OF BUSINESS IMPACTED
COMMERCIAL	ACA QHP	SMALL GROUP ACA	JAA	FEP	Medicare Advantage (BlueCard)	Dental
The BLUE highlighted box is the line of business impacted by this update.

Have you noticed our new-look Blue KC Provider Portal login page at Providers.BlueKC.com?

Blue KC is making it easier for you to get the information you need by providing additional quick access link options that take you directly to the section of the portal you are interested in seeing.

Here’s how this new section appears on the login page:

Make sure to log in to take advantage of all the Blue KC Provider Portal functions, including submitting a new or viewing an existing prior authorization and our provider data forms. Here are some helpful forms on our Portal:

• General Inquiry Form
  • For a faster way to answer your questions.
• 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.

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.

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