Pharmacy Policy Updates

Biosimilar Products to Replace Humira Effective January 1, 2025

To maintain our commitment to providing our members with the most effective therapies at the lowest possible cost, Blue Cross and Blue Shield of Kansas City (Blue KC) will no longer cover Humira for most commercial members effective January 1, 2025, but we will cover the following three biosimilars:

Simlandi

Adalimumab-adbm (Unbranded Cyltezo)

Amjevita (Nuvaila)

• Biosimilars are highly similar to FDA-approved biological reference products. There is no clinically meaningful difference in their safety or effectiveness. Only minor differences in clinically inactive components are allowed.
• Members affected by this change will receive a letter informing them to contact their physician to request a new prescription.
• All specialty drugs require prior authorization (PA). All active PAs for Humira will automatically be applied to the biosimilars listed above for the remainder of the approval time left on the PA.
• If a patient chooses to continue Humira, the patient will be responsible for 100% of the cost.

Pharmacy Policy with Changes

The following Blue KC pharmacy policy will include the following changes effective October 1, 2024. This policy only impacts our Commercial line of business and requires prior authorization:

Pharmacy Policy with Changes
Policy Number	Policy Name	Summary of Changes
5.01.24	Rituxan® (rituximab) and biosimilars	Require failure of all preferred biosimilars instead of just one

New Pharmacy Policy

The following Blue KC pharmacy policy became effective September 1, 2024, only impacts our Commercial line of business and requires prior authorization:

New Pharmacy Policy
Policy Number	Policy Name	Summary of Changes
5.02.662	Adzynma (ADAMTS13, recombinant-krhn)	FDA Approved for Congenital Thrombotic Thrombocytopenic Purpura (cTTP); IV; Medical-Rx benefit

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Prior Authorization Updates

Online Prior Authorization Made Easy for You!

Did you know you can submit and view status of your prior authorizations online using the Blue KC Provider Portal?

To use our Enhanced Prior Authorization feature, log into Providers.BlueKC.com and follow these steps:

• Login is required to use the Blue KC Provider Portal prior authorization tool. Please select “Create Account” on the Provider Portal login page and follow the steps.
• Once you log in and arrive on the home page, click on “Prior Authorization.”
• Enter the Member ID and click the “Submit Prior Authorization” button to determine if prior authorization is required and submit new prior authorization requests. (The Member’s prefix may be entered but isn’t required.)
  • If you input an FEP Member ID number, and then select “Submit Prior Authorization”, you will be immediately directed to the Guiding Care site.
  • If the ID is related to more than one member on the plan, everyone on that plan will be displayed and you will select the appropriate member.
• Next, open the dropdown where you can “Search for any Procedure, Code or Drug name” and make your selection. The dropdown also has ‘type-ahead capability’ that will dynamically display things like CPT code, name of the procedure or the name of the drug as you begin to search.
• After making your selection, you will be presented with a Disclaimer and a “Submit Prior Authorization” button if a prior authorization is needed for the code, service or drug name you’ve entered. In some cases, an “Authorization Type” dropdown will display. This is based on if the selected code is a Medical Service for Inpatient, Outpatient or a drug on the medical benefit.
• Lastly, you will be directed to the proper Blue KC vendor Portal to complete entry of your “electronic prior authorization”. Please note that you may be routed to other partner sites, such as eviCore or Avalon, depending upon the type of prior authorization request.
• To view an existing electronic prior authorization request, select “Prior Authorization” from the home page or main navigation. You will be directed immediately to the Member ID input page where you can select the “View History” link. This link will direct you to the Guiding Care Portal for a list of previously entered prior authorizations.
• Find more guides, tips, and video tutorials by visiting the “How to Use the Provider Portal” section on the Blue KC Provider Portal.

DME Code Updates

Effective November 1, 2024, Blue KC will be expanding our prior authorization management for Durable Medical Equipment (DME). This will impact our Commercial, Blue Medicare Advantage, ACA QHP for Individual/Family and Small Group ACA lines of business.

Here is the list of CPT codes for DME that will be impacted, effective November 1, 2024:

DME Code	DME Description	Effective date	Lines of Business (LOB)
E1240	Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E1250	Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are non-covered)
E1260	Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are non-covered)
E1270	Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E1280	Heavy-duty wheelchair, detachable arms (desk or full-length) elevating legrests	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E1285	Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E1290	Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are non-covered)
E1295	Heavy-duty wheelchair, fixed full-length arms, elevating legrest	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
K0003	Lightweight wheelchair	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
K0004	High strength, lightweight wheelchair	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
K0005	Ultralightweight wheelchair	11/1/2024	Will add PA for all LOB
K0006	Heavy-duty wheelchair	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA
K0007	Extra heavy-duty wheelchair	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA
E0983	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control	11/1/2024	Will remove PA and add as non-covered for Commercial/ACA (Currently: Commercial/ACA/MA have PA)
E0984	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control	11/1/2024	Will remove PA and add as non-covered for Commercial/ACA (Currently: Commercial/ACA/MA have PA)
E0985	Wheelchair accessory, seat lift mechanism	11/1/2024	Will add PA for all LOB and remove as non-covered for Commercial/ACA (Currently: Commercial/ACA are non-covered; MA is covered with no PA)
E0988	Manual wheelchair accessory, lever-activated, wheel drive, pair	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E8000	Gait trainer, pediatric size, posterior support, includes all accessories and components	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA are covered with no PA; MA is non-covered)
E8001	Gait trainer, pediatric size, upright support, includes all accessories and components	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA are covered with no PA; MA is non-covered)
E8002	Gait trainer, pediatric size, anterior support, includes all accessories and components	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA are covered with no PA; MA is non-covered)
E1017	Heavy-duty shock absorber for heavy-duty or extra heavy-duty manual wheelchair, each	11/1/2024	Will add PA for ACA/MA (Currently: Commercial is covered with PA; ACA/MA are covered with no PA)
E1018	Heavy-duty shock absorber for heavy-duty or extra heavy-duty power wheelchair, each	11/1/2024	Will add PA for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E2358	Power wheelchair accessory, group 34 non-sealed lead acid battery, each	11/1/2024	Will change from covered to non-covered for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E2360	Power wheelchair accessory, 22 NF non-sealed lead acid battery, each	11/1/2024	Will change from covered to non-covered for all LOB (Currently: Commercial/ACA/MA are covered with no PA)
E2362	Power wheelchair accessory, group 24 non-sealed lead acid battery, each	11/1/2024	Will change from covered to non-covered for all LOB (Currently: Commercial is covered with no PA; ACA/MA have PA)
E2364	Power wheelchair accessory, U-1 non-sealed lead acid battery, each	11/1/2024	Will change from covered to non-covered for all LOB (Currently: Commercial is covered with no PA; ACA/MA have PA)
E2371	Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each	11/1/2024	Will add PA for Commercial (Currently: Commercial is covered with no PA; ACA/MA have PA)
E2372	Power wheelchair accessory, group 27 non-sealed lead acid battery, each	11/1/2024	Will change from covered to non-covered for all LOB (Currently: Commercial is covered with no PA; ACA/MA have PA)
E8000	Gait Trainer	11/1/2024	Will add PA for all LOB
E8001	Gait Trainer	11/1/2024	Will add PA for all LOB
E8002	Gait Trainer	11/1/2024	Will add PA for all LOB
E0601	CPAP	11/1/2024	Will add PA for all LOB
L1832	Knee Brace	11/1/2024	Will add PA for all LOB
L1833	Knee Brace	11/1/2024	Will add PA for all LOB
L1834	Knee Brace	11/1/2024	Will add PA for all LOB
L1840	Knee Brace	11/1/2024	Will add PA for all LOB
L1843	Knee Brace	11/1/2024	Will add PA for all LOB
L1844	Knee Brace	11/1/2024	Will add PA for all LOB
L1845	Knee Brace	11/1/2024	Will add PA for all LOB
L1846	Knee Brace	11/1/2024	Will add PA for all LOB
L1847	Knee Brace	11/1/2024	Will add PA for all LOB
L1848	Knee Brace	11/1/2024	Will add PA for all LOB
L1850	Knee Brace	11/1/2024	Will add PA for all LOB
L1851	Knee Brace	11/1/2024	Will add PA for all LOB
L1852	Knee Brace	11/1/2024	Will add PA for all LOB
L1860	Knee Brace	11/1/2024	Will add PA for all LOB
E0470	Respiratory Assist Device	11/1/2024	Will add PA for all LOB
E0471	Respiratory Assist Device	11/1/2024	Will add PA for all LOB
E0472	Respiratory Assist Device	11/1/2024	Will add PA for all LOB

Additional Code Updates

The codes below will be added to our prior authorization list, effective November 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	Lines of Business (LOB)
0345T	Transcatheter mitral valve repair percutaneous approach via the coronary sinus	11/1/2024	Will add PA for Commercial (Currently: Commercial is covered with no PA; ACA/MA have PA)
41530	Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session	11/1/2024	Will add PA for MA (Currently: Commercial/ACA are non-covered; MA is covered with no PA)
44715	Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein	11/1/2024	Will add PA for Commercial (Currently: Commercial is covered with no PA; ACA/MA have PA)

CPAP Prior Authorization

Upon confirmation that prior authorization requirements are met, authorization will be approved for a duration of 12 weeks.

Continued coverage (beyond first 12-weeks of therapy) for CPAP may be indicated for 1 or more of the following:

• Clinical re-evaluation conducted by treating practitioner no sooner than 31st day, but no later than 91st day, after initiating therapy with documentation supporting compliance and effectiveness of therapy as indicated by BOTH of the following:
• Practitioner documents symptoms of OSA are improved.
• Objective evidence of adherence to use of PAP device reviewed by treating practitioner defined as the use of the PAP device ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the 12-weeks of initial usage.
• Members who do not meet the criteria above and, therefore, fail the initial 12-week trial are eligible to re-qualify for a second PAP device trial, without a repeat sleep study, within a 2-year period from the initial trial, when:
• Face-to-face clinical re-evaluation by the treating practitioner determines the etiology of the failure to respond to PAP therapy (documenting desire for retrial / barriers to past compliance / ongoing sleep disordered breathing symptoms and an order for PAP).

Note: Utilizing our Blue KC Provider Portal for optimal efficiency, streamlined communication and instant approval is highly recommended.

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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.

New Policy

Effective date – 10/1/2024

ID: 5.01.51 Title: Tumor-Infiltrating Lymphocytes for Advanced Melanoma Tumor-infiltrating lymphocyte therapy with a therapy approved by the U.S. Food and Drug Administration (FDA) (e.g. lifileucel) may be considered medically necessary as a second-line treatment option in individuals with unresectable or metastatic melanoma previously treated with anti-programmed cell death-1 and, if BRAF V600 mutation positive, a BRAF inhibitor with or without a MEK inhibitor. The use of lifileucel for all other indications is considered investigational.

Updated Policies
Effective date – 10/1/2024	ID: AHS – M2083 Title: Genetic Testing for Ophthalmologic Conditions New CC2: “2) For individuals with clinical findings suggestive of other ophthalmologic disorders with a known causative gene(s) where identification of a genetic variant will affect clinical management, testing of the known causative gene(s) is considered medically necessary.
Effective date – 10/1/2024	ID: AHS – M2021 Title: Pharmacogenetic Testing New CC14: “14) When formulary coverage allows a pharmacotherapy that is dependent on a known genetic status (e.g., APOE testing prior to lecanemab-irmb treatment), gene specific testing is considered medically necessary.”
Effective date – 10/1/2024	ID: AHS – M2179 Title: Prenatal Screening (Genetic) Updated language in CC3 so that it’s abundantly clear that screening in the reproductive partner is restricted to the genes for which their partner tested positive by carrier screening, not broad screening for themselves. Now reads: “3) For individuals planning a pregnancy with a reproductive partner who is known or found to be a carrier of a recessively inherited disorder, genetic testing specific to the genes for which the reproductive partner is a carrier is considered medically necessary.” Updated language in CC5 so that it’s clear that fetal testing must be a form of testing, not a form of screening (e.g., cfDNA screening), from an amnio or CVS sample. Now reads: “5) For fetuses with a high risk for a genetic disorder, prenatal genetic testing using cells obtained for diagnostic cytogenetic testing (i.e., amniocentesis or chorionic villus sampling [CVS]) is considered medically necessary.” New CC7: “7) To screen for single-gene mutations (i.e., autosomal recessive, autosomal dominant, X-linked) in the fetus, the use of non-invasive prenatal screening (NIPS) is considered investigational.”

Interim Updates
Effective date – 10/1/2024	ID: 8.01.68 Title: Omidubicel as Adjunct Treatment for Hematologic Malignancies Policy statements changed to: Omidubicel is considered medically necessary in individuals 12 years or older with hematologic malignancies planning myeloablative allogenic umbilical cord transplantation to reduce the time to neutrophil recovery and the incidence of infection. Policy changed from investigational to medically necessary when criteria met.
Effective date – 10/1/2024	ID: 7.03.02 Title: Allogeneic Pancreas Transplant Policy Guidelines updated to remove obesity-related criteria. No change to policy statement
Effective date – 10/1/2024	ID: 5.01.33 Title: Brexanolone for Postpartum Depression Policy updated with literature review through July 9, 2024; new PICO for zuranolone added. Relevant references added. Policy statements updated to reflect updated literature and new PICO.
Effective date – 10/1/2024	ID: 2.02.19 Title: Catheter Ablation as Treatment for Atrial Fibrillation Added pulsed field ablation as investigational.

Existing MCG Guidelines with Changes
Effective date – 10/1/2024	ID: BKC-A-0431 Title: Continuous Positive Airway Pressure (CPAP) Device – Interim Update Addition of initial 12-week period New & revised criteria for “initial” 12-week period Addition of continued coverage beyond first 12-weeks of therapy New & revised criteria for “continuation” beyond 12-week period Guideline nomenclature changed from A-0431 to BKC-A-0431
Effective date – 10/1/2024	ID: BKC-A-0886 Title: Gait Trainer – Interim Update Addition of criteria for members over the age of 18 “Gait trainers for members over the age of 18 will be considered on a case-by-case basis. Considering member size and historical use as well as the criteria below.” Guideline nomenclature changed from A-0886 to BKC-A-0886

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Payment Policy Updates

New Clinical Edits

Effective October 1, 2024, Blue KC will implement the following two new Clinical Edits:

• Code Inappropriately billed with modifier JW.
  • Blue KC requires providers and suppliers to include a JW modifier, and the corresponding units wasted on all claims where drug waste occurs. Per the U.S. Food and Drug Administration (FDA), certain drugs do not warrant any waste due to the approved dosage, drug form, and/or preparation requirements. Any of these specific drugs billed with a JW modifier will be denied for all corresponding drug wastage lines.
• High level ER Visit Billed Same Day as Hospital Discharge To Home.
  • CPT® 99285 is defined as, “Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.”  According to the CPT® MDM grid, to establish a high level of medical decision making, 2 out of the 3 following must be met:
    1. A high number and complexity of problems addressed, or
    2. An extensive amount and/or complexity of data to be reviewed and analyzed, or
    3. High risk of complications and/or morbidity/mortality of patient management
    If the provider bills CPT® code 99285 and the corresponding facility claim for the same date of service indicates a discharge status of 01 (discharge to home or self-care), CPT® 99285 will be denied per payor policy.

Two-Midnight Rule

Payment Policy POL-PP-251 for Two-Midnight Rule will become effective October 1, 2024. Here are more details:

• Blue KC follows the payment criteria for inpatient admissions such as the “Two-Midnight Rule.”
• We comply with general coverage and benefit conditions included in Original Medicare laws, unless superseded by laws applicable to Medicare Advantage plans. This includes payment criteria for inpatient admissions at 42 CFR 412.3, such as the “two-midnight benchmark” (§ 412.3(d)(1)).
• All hospital services must be reasonable and necessary to be covered at the inpatient level.
• Blue KC will use medical necessity criteria in determining hospital admissions.
• Milliman Care Guidelines will be used as the source of medical evidence to determine whether the complex medical factors documented in the patient’s medical record support the admitting physician’s reasonable expectation that the patient requires hospital care that crosses 2 midnights.

Modifier SU

Payment Policy POL-PP-250 for Modifier SU became effective on August 13, 2024. Here are more details:

• Modifier SU denotes the use of the facility and equipment for a procedure performed in a physician’s office.
• Relative Value Units (RVU) for CPT and HCPCS codes include the costs of running an office (such as rent, equipment, supplies and nonphysician staff costs), which are referred to as the practice expense RVU.
• Consistent with the approach taken by CMS, Blue KC reimburses its providers for procedures performed in their offices in a manner which takes into account the costs associated with running an office (i.e., overhead, etc.), and as such, Blue KC shall not reimburse separately for services appended with modifier SU.
• To view this payment policy, visit Providers.BlueKC.com, and click on Go to Payment Policies. The policy will be included in the “New Payment Policies (published within the last 30 days)” section.

Gastrointestinal Endoscopies and Related Services

Gastrointestinal Endoscopies and Related Services (POL-PP-216) received these updates, effective August 9, 2024:

• Anesthesia for a screening colonoscopy and screening colonoscopy converted to polypectomy are billed with code 00812.
• A screening colonoscopy is a test provided to a patient in the absence of signs or symptoms and is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is found does not change the screening intent of that procedure.
• Anesthesia for a diagnostic or therapeutic colonoscopy is reported with CPT code 00811.
• Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign, or symptom (such as abdominal pain, bleeding, diarrhea, etc.).
• When multiple endoscopies from the same endoscopic family are performed on the same date of service, payment will be bundled into the primary endoscopy procedure for providers who were re-contracted or newly contracted on or after June 1, 2021.
  • The Endoscopic Procedure with the highest fee schedule amount is reimbursed at the full value of the contracted rate. For additional endoscopies within the same endoscopic family, we will subtract the contracted rate of the base endoscopy and reimburse the difference.
  • While the secondary line will show as $0.00, the total payment is added to the line with the highest fee schedule rate. The secondary line is “bundled,” it is not denied. Please review the total allowance paid before submitting an inquiry.

Preventive Medicine Services

Payment Policy POL-PP-128 for Preventive Medicine Services has received the following update regarding the collection of the pap smear:

• If performing a screening Pap smear during a Medicare Annual Wellness Visit, it would be appropriate to report G0348-G0349 with Q0091 (Screening Papanicolaou smear, obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). If performing an office visit (99202-99205, 99212-99215) or a preventive medicine visit (99381-99387, 99391-99397), the Pap smear collection is considered to be part of the visit and is not separately billable.

Clinical Trials

The Clinical Trials Payment Policy POL-PP-248 became effective July 15, 2024. Here are highlights:

• Blue KC complies with the Federal Patient Protection and Affordable Care Act by allowing reimbursement for routine costs related to certain clinical trials.
• All services provided as part of a clinical trial, such as S9988, S9990, S9991, S9992, S9994, S9996, G0293 and G0294 must be billed with the modifier Q0 or Q1. Additionally, the service must be billed with ICD-10 diagnosis code Z00.6 in either the primary or secondary position of the diagnosis codes on the claim.
• It is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries.
• To view the full policy, 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.

In-Network Skilled Nursing Facility Gold Card

Payment Policy POL-PP-249 for Skilled Nursing Facility Gold Card became effective July 15, 2024, and applies to Commercial, Blue Medicare Advantage and Small Group ACA. Here are more details:

• During the COVID-19 public health emergency, Blue KC waived prior authorization for admission to in-network Skilled Nursing Facilities (SNF). This policy was known as the SNF Waiver of Prior Authorization. Blue KC is formalizing this move with the creation of the Gold Card Payment Policy, which follows the same guidelines.
• Gold carding is part of the “Prior Authorization and Utilization Reform Principles” (PDF) that came out of an AMA-convened workgroup with 16 state and specialty medical societies, national provider associations and patient representatives.
• In line with the AMA’s effort to reduce the volume of prior authorization requests, Blue KC will not require a prior authorization for admittance to SNFs. Notice of admission will still be required, per terms of the facility contract and member certificate. All SNF admissions are subject to concurrent review for ongoing medical necessity, per Blue KC Utilization Management protocol.
• To view this payment policy, visit Providers.BlueKC.com, and click on Go to Payment Policies. The policy will be included in the “New Payment Policies (published within the last 30 days)” section. More details are also featured in the SNF Gold Card article on our Provider Portal home page under Recent News.

Medically Unlikely Edits (MUE’s)

Blue KC wants to remind you that our Payment Policy Medically Unlikely Edits (MUE’s) became effective July 1, 2024.

• 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 are 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 is not acceptable.
• 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.

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Blue Medicare Advantage Updates

Medicare Advantage Term Notice

Blue KC announced that it will end its participation in Medicare Advantage and its agreement with CMS will terminate effective January 1, 2025.

This notice serves as a notification of the automatic termination of the Medicare Advantage Addendum to your Blue KC network participation agreement. The termination is effective on January 1, 2025.

Please note that this termination is limited to the Medicare Advantage Addendum and your participation in the Medicare Advantage networks. This will not impact any other part of your Blue KC network participation agreement or your participation in any other Blue KC network or product.

Claims for members of another Blue Cross and Blue Shield Medicare Advantage plan who reside in the Blue KC service area are subject to the benefit terms and coverage under their plan. Please call the customer service number on the member's ID card to verify coverage.

We appreciate your partnership to provide care to our Medicare Advantage members.

If you have questions about this notification, please contact us at 816-508-7140.

Top 5 Claim Denial Reasons and How to Avoid Them

1. This claim was submitted after the time limit for filing claims.

Per the Provider Reference Guide:

Timing Overview
Primary	In the Blue KC Physician Network Agreement, we ask that claims be filed within 30 days of the date of service but no later than 180 days in order to be considered for payment.
Secondary	Claims should be filed witin 180 days of the date of service or 90 days form the primary carrier's payment date with the Primary payer remittance. Blue KC accepts secondary claims electronically.

2. Member not eligible for benefits.

Per the Provider Reference Guide:

Before any services are rendered, Provider must conduct a member verification under each benefit plan. Once verification is in place, Provider shall provide timely accessibility to members. An individual’s possession of a membership ID card is not a guarantee of eligibility or benefits. Always verify eligibility and benefits in advance of providing (non-urgent or non-emergent) services. Always verify another form of legal photo identification, such as a driver’s license, passport or other government issued ID, to help prevent identity theft.

Member eligibility and benefits can be verified:

• Online at Providers.BlueKC.com.
• By calling our Blue Medicare Advantage Provider Hotline at 866-508-7140.

3. The procedures exceed the allowed number of units that may be submitted, according to CMS guidelines.

Per the Blue KC Payment Policy POL-PP-246 Medically Unlikely Edits:

For Medicare Advantage claims, providers will be allowed to submit documentation in support of units over the MUE allowed amount. Documentation must clearly explain why the excess units were necessary. A statement merely indicating that the patient required additional units is not acceptable.

Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.

MUE’s are published with an adjudication indicator. The MUE adjudication indicator (MAI) indicates the type of MUE and its basis. The MAI assigned to HCPCS/CPT codes will determine how the claim will process and/or deny.

MAI of 1

MUE’s for CPT/HCPCS codes with a MAI of “1” will continue to be adjudicated as a claim line edit.

Blue KC adjudicates MUEs against each line of a claim rather than the entire claim. Thus, if a CPT/HCPCS code is reported on more than one line of the claim by using CPT modifiers, each line with that code is separately adjudicated against the MUE.

CPT modifiers such as 59 X-[EPSU], -76, -77, and anatomic modifiers (e.g., RT, LT, FA-F9, TA-T9), -91, will accomplish this purpose. If a provider bills units of service for HCPCS/CPT codes in excess of established limits, the edits prevent payment. Blue KC denies at the line level rather than the claim level for both Physician and Facility claims.

MAI of 2

MUEs for HCPCS codes with a MAI of “2” will be an absolute date of service edit. These are “per day edits based on policy.”

HCPCS codes with an MAI of “2” have been rigorously reviewed and vetted within CMS and obtain this MAI designation because units of service (UOS) on the same date of service (DOS) in excess of the MUE value would be considered impossible because it was contrary to statute, regulation, or sub regulatory guidance.

This sub regulatory guidance includes a clear correct coding policy that is binding on both providers and CMS claims processing contractors.

MAI of 3

MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks”. 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 MUE’s with a MAI of 3, Blue KC will reimburse up to the allowed amount found on the NCCI Medically Unlikely Edits table. Units billed in excess of the allowed amount will be denied. NCCI Medically Unlikely Edits table can be found here:

https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-medically-unlikely-edits

4. Authorization was not obtained. Therefore, the services are not covered under the member’s contract.

Per Blue KC’s Provider Reference Guide: A complete list of services requiring prior authorization may be found at Providers.BlueKC.com. Blue KC performs a pre-review of selected outpatient and inpatient procedures for all Blue KC programs, including lease and ASO business.

• The prior authorization process begins when a Provider, facility, member or the member’s representative contacts Blue KC’s Prior Authorization/Clinical Operations Department for authorization regarding a member’s pending procedure, service or medication.
• Blue KC staff verifies the member’s eligibility or, if after business hours will take the necessary information to verify eligibility the next business day. Specially trained registered nurses or pharmacists gather clinical information about the proposed service. Based on medical review findings, the Prior Authorization/Clinical Operations Department confirms the need for the service.
• If the nurse or pharmacist is not able to approve the case, it will be referred to the medical director for review.
• As of February 1, 2020, Blue KC is no longer accepting medical pre-determination requests from providers for commercial plans.

To access the Blue KC medical policy, go to Providers.BlueKC.com. If members have questions, they should contact the Prior Authorization/Clinical Operations Department. Contact resources are located in the Contact Resource Directory. Also, for providers answers to questions about specific benefits are available through the Providers. BlueKC.com or the Provider Hotline during business hours. When requesting prior authorization, the Provider will need the following member-specific information on the prior authorization form:

1. Blue KC staff requests the following information at the time of the call:
   • Caller’s name and telephone number.
   • Admitting/Service Provider.
   • Member’s name and birth date.
   • Blue KC Identification number and Group number.
   • Proposed treatment plan: tests, diagnostic procedures, surgical procedures, treatment, etc.
   • Date, place and type of admission or service.
   • Diagnosis primarily responsible for the admission or service.
   • Provider number and Group number.
2. Blue KC staff verifies that the treatment plan meets the criteria based on MCG or Blue KC medical policy.
3. If the admission or service is approved, the Blue KC nurse notifies the Provider and requester within 36 hours (to include one business day) upon receipt of all necessary information. A letter will be generated within 1 business day following approval. For admissions, the nurse also assigns a length of stay.
4. If the nurse is unable to approve the services(s) or elective admission, the case is referred to the medical director for review.
   
   Prior Authorization > Required Member Information
5. The Blue KC Medical Director makes a determination based on the clinical information provided. If more information is necessary, the medical director or review nurse contacts the Provider to request the additional information before a determination is made.
6. If the authorization is denied, the Provider may file a standard appeal to the appeals department or an expedited appeal to the Medical Director by calling or in writing (see Contact Resource Directory for details).

5. Billed claim lines are disallowed when billed with an acute diagnosis code and POS 11.

Per Blue KC payment policy POL-PP-228 Risk Adjustment and Acute Inpatient Diagnosis:

CMS compensates Medicare Care Organizations (such as Blue Cross Blue Shield of Kansas City) using a risk adjustment payment methodology. This methodology assigns members a clinical risk score that is calculated based on their medical conditions and demographic/socio-economic factors.

In September 2020, the Office of Inspector General (OIG) published a report that identified CMS overpayments to health plans due to providers in professional settings over-coding of acute conditions. The report identified the need for health plans to ensure providers in professional settings do not inappropriately document acute conditions where the patient’s severity of illness and/or servicing the patient’s medical conditions are performed in an inpatient setting.

To adopt OIG’s recommendations, Blue Cross Blue Shield of Kansas City requests providers shall not charge, bill, or collect a fee when an acute inpatient diagnosis is submitted with POS 11 (office).

When a patient is seen in an outpatient setting, conditions that are no longer active and/or not being treated should not be actively reported; this includes problem list diagnoses that have been resolved. When a diagnosis no longer exists and has been resolved, document as “history of.” Examples include a history of a cerebrovascular accident (CVA) or history of a myocardial infarction. Report history of and status codes when pertinent and/or influential to the current care or treatment.

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Network Update

We are happy to report that Blue KC and Kansas City Orthopaedic Institute (KCOI) were able to resolve the dispute regarding the physical therapy services and enter into a new contract effective on September 17, 2024, avoiding any interruption to the availability of in-network services at KCOI for Blue KC members.

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Provider Education

Timely Filing Claim Adjustments

Blue KC is pleased to provide the following helpful information for timely filing:

• Verify insurance and confirm eligibility upon patient arrival to avoid timely filing denials.
• Claims must be submitted no later than 180 days after the date of service to be eligible for payment.
  • Exception: If another Policy paid primary in error and later recoups their payment, you may request we waive Timely Filing within 90 days of notification from the other Policy.
  • Coordination of Benefits: If Blue KC is secondary, the claim must be submitted to the secondary policy within 90 days of the primary policy’s payment date (this includes instances where Blue KC is also the primary policy).
• Claim adjustments and corrected claims must be submitted within 12 months of the original paid date for claims previously processed by Blue KC.
• For more details on timely filing, log in to your account on Providers.BlueKC.com, and click on “Resources”. Timely filing is featured on page 5 in the Claims, Billing and Remittance section of our Provider Reference Guide.

Verify Your Information Through CAQH Attestation

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

Blue KC, along with CMS and NCQA, require providers to attest their data in CAQH every 90 days, and it’s a requirement in our credentialing process. Lack of quarterly attestation will result in the provider being suppressed from the Blue KC Directory and could lead to provider termination.

New Email Address for EDI Questions

Do you have a question related to Electronic Data Interchange (EDI)?

Blue KC has a new email address that providers can use to ask questions about EDI and electronic claim submissions. The email address is ProviderEDI@BlueKC.com.

This email goes to the Operations Data Exchange Services team, which is a newly formed team under Blue KC’s Operations division that is dedicated to supporting providers with EDI/electronic claims questions.

Billing Tips for Clinisol

Blue KC wants to provide guidance to providers regarding the billing process for Clinisol. Specifically, a significant number of claims show providers are billing a J3490 code for Clinisol. This product has its own B code, so we want to make sure providers bill with the appropriate B code instead of using the J3490 code to avoid having their claims returned. Here is the list of B codes to help you know which one to use:

B Code	Description
B4189	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix
B4193	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix
B4197	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix
B4199	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix

How to Identify JAA Accounts

Have you wondered how you can identify if one of your patients is a Blue KC Joint Administrative Account (JAA) member just by looking at the patient’s Blue KC member ID card?

There are two ways to identify if a card belongs to JAA:

• All JAA Groups have a Blue KC member ID number that begins with 850000, and the last two digits of the number specific to the JAA Group (00 – 09).
• The Customer Service phone number on the front / bottom left of the ID card is not the standard Blue KC Customer Service number but is a phone number to JAA’s TPA or Benefit Administrators Office.

EFT Form Enhancements

Blue KC is pleased to bring enhancements to the Electronic Funds Transfer (EFT) Request Form:

• The EFT form has transformed into an easier-to-use Qualtrics based form.
• The form is submitted online with the click of a button after answering questions on a series of screens.
• To find the form, visit the log-in page at Providers.BlueKC.com and click on Forms.

Requirement for Provider Network Change

For your awareness, CAA, CMS and NCQA require Blue KC to send a provider termination notice to members if the members have seen a provider who has terminated from their plan’s Network.

• Blue KC must notify members who have seen the provider within a set lookback period.
• For a non-Blue Medicare Advantage member, the lookback period is 12 months.
• For a Blue Medicare Advantage member, the lookback period varies depending on provider type.
• For example, a provider could be terminated from a Blue KC network if CAQH information is not updated. We would send a letter advising members that the provider was termed.

Inactivity Policy

To ensure Blue KC’s provider data is current and accurate, providers who have not actively serviced a Blue KC member and submitted claims in the preceding 12 months will receive a termination letter due to inactivity.

• The termination is specific to the provider under the group name and tax ID listed in the letter.
• If the provider is with a new group or under a new tax ID, and claims are being submitted and processed under that group, the termination will not affect that record.
• The provider can request a six-month extension by emailing Inactive_Provider@BlueKC.com within 30 days after the date of the letter.

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.

Help Ensure our Members Receive their COVID-19 and Flu Vaccines

To help keep our members healthy this fall, we want to provide information regarding the vaccine for both the flu and COVID-19. The updated COVID-19 vaccine is available to Blue KC members for $0.

Anyone can search vaccines.gov to find a COVID vaccine provider near them. By the end of September, the federal government plans to resume its free at-home COVID test program. The website, COVIDTests.gov, has more information.

The CDC recommends a single dose of the updated, mRNA COVID-19 vaccine for anyone six months or older. It is especially critical for individuals who are:

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• Immunocompromised
• 65 or older
• Living in a long-term care facility
• Pregnant or trying to get pregnant
• Breastfeeding
• Have never received the COVID-19 vaccine

Blue KC also wants to create provider awareness on the importance of our high-risk members receiving the flu vaccine for the best protection against getting the flu. According to the CDC, everyone six months and older in the United States, with rare exceptions, should get a flu vaccine every season. Blue KC health plans cover 100% of the cost of the vaccine when it is administrated by an in-network provider.

Individuals 65 and older contribute to most seasonal flu-related hospitalizations (50% to 70%) and deaths (70% to 85%). However, people with chronic heart and lung conditions may be associated with an even greater risk of flu complications.

Learn more in this video featuring Kansas City Pro Football Hall of Fame member Bobby Bell.

Source for article: Centers for Disease Control and Prevention, https://www.cdc.gov/flu/highrisk/65over.htm, https://www.cdc.gov/flu/highrisk/heartdisease.htm.

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Health Equity

Blue KC and Black Health Care Coalition Host CPR Education Event

To address health disparities and give life-saving information, Blue KC was proud to partner with the Black Health Care Coalition to host training for infant and adult CPR on September 21 at the Jamison Memorial Temple in Kansas City, MO.

Disparities have been found in survival rates for people receiving CPR by a non-medical professional for cardiac arrest. A National Institutes of Health (NIH)-supported study revealed that average survival benefits for cardiac arrest could be three times as high for white adults compared to Black adults and twice as high for men compared to women.

At the September event, more than 100 Kansas City area residents received accurate, proven training to help them respond with life-saving skills in emergency situations. The American Heart Association led the CPR training. Participants who completed the course received a free CPR training kit. To learn more about the event and health disparities associated with CPR, click here to watch a video featuring Blue KC Director of Population Health Larry Franken and Black Health Care Coalition President Melissa Robinson.

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Community Investment

Answering the Call

Earlier this month at Kauffman Stadium, Blue KC celebrated our six courageous “Answering the Call” honorees from the 2023 season. The Blue KC Answering the Call award is a partnership between Blue KC and the Kansas City Royals to salute first responders who make a difference in our community.

Since 2021, Blue KC has honored more than 30 front-line heroes who have embodied what it means to serve others. The program has involved a list of professions, ranging from Police Dispatchers, Detectives, Firefighters, Juvenile Detention Officer, Crisis Intervention Officer, Paramedic Officer and everything in between!

For more information on the program and to learn more about our wonderful heroes, click here.

New Youth Behavioral Health Video

In the previous issue of BlueSpeak, we told you about a new partnership between Blue KC, Children’s Mercy Kansas City and the Center School District to tackle the youth mental health crisis. Recently, Children’s Mercy Licensed Psychologist Stefanie Schrieber, Center High School Match Teacher Diana Elkishawi and Blue KC Behavioral Health Program Manager Kristin Gernon joined us for a powerful discussion on youth behavioral health and our new three-year early intervention pilot program. Click here to watch the video.

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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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