When you visit a doctor or hospital, they work with Blue KC to file a claim on your behalf. A claim is a detailed invoice that shows exactly what services you received. Usually, your healthcare provider files claims for you.
Your claims are outlined on an Explanation of Benefits (EOB). It’s your go-to reference for important information about how much of your care was covered and how much you may still need to pay. If you’re interested in learning more, please visit the Explanation of Benefits (EOB) 101 section of the member portal for a detailed overview of how to read the information on your EOB.
Following are some common questions regarding the claims process:
1. Who is responsible for submitting a claim?
Any time you visit an in-network provider, they will submit a claim to Blue KC on your behalf for the services you obtain.
If you decide to visit an out-of-network or non-contracted provider, you will need to confirm whether they will be submitting a claim on your behalf or not. If the provider is not planning to send us that claim, you can submit a claim yourself to ensure any payments you made to that provider count towards your deductible and out-of-pocket maximum amounts. Based on your plan usage and benefits, Blue KC may pay a portion (or all of) the provider charges, and you will be reimbursed accordingly.
2. Do I pay my provider at the time of service?
If your plan’s benefits require a copay, then you will need to pay the provider that amount at the time of service. You may owe an additional amount to that provider once your claim processes based on your plan’s benefits and how much you have already paid towards your deductible and out-of-pocket maximum.
3. How long do providers or members have to submit a claim?
In-Network and contracted providers have six months from the date of the service to send Blue KC claims to be processed. However, many providers will send us claims much sooner after your visit.
If you need to submit a claim after seeing an out-of-network or non-contracted provider, you have one year following the end of the year the service was rendered. For example, if you receive care on May 1st, 2022, you have until December 31st, 2023, to submit your claim. However, we recommend you submit your claim as soon as possible.
4. How do I submit a claim and what information needs to be included?
The easiest way to submit a claim is through our online form, which you can find in your member portal. Log in at MyBlueKC.com, select the Claims, EOB, & Usage tab in the left navigation menu, then click Submit A Claim.
You will see a few different claims forms available to you, so you will need to select the one that best applies to the services you received.
To ensure your claim processes, make sure you include an itemized bill from your provider that lists, line-by-line, the services you obtained and the charges for each individual service. The bill should include the name of the person receiving these services, as well as the provider’s name.
5. How long do claims take to process?
If you receive care from a provider within Blue KC’s coverage area (32 counties surrounding the Kansas City metro), we will process the claim within 30 business days of receiving it.
When you receive care from a provider outside of our coverage area – for example, you visited an urgent care while on vacation in Colorado – processing times can increase to about 90 days from the date we receive the claim.
6. I received a check from Blue KC – what is it for?
When you see an out-of-network provider, we send a check that is attached to the last page of the EOB you receive in the mail. Please do not throw away mail from Blue KC without reviewing it first!
Since the provider didn’t send us a claim, you are responsible for paying them directly. The check enclosed is for the amount that Blue KC is paying towards the services you received. Use this check to help towards that payment you’re making.
Your EOBs are always available in your member portal under the Claims, EOB & Usage section, online at MyBlueKC.com, or through the MyBlueKC app. Interested in paperless EOBs? Sign-up for email or text notifications when a claim is ready to view. Simply update your Communication Preferences today!