Prior authorization
Blue KC wants you to receive the most effective, appropriate treatment available. We also want to protect you from incurring additional or unnecessary costs. That’s why we require your healthcare provider to get approval—also known as prior authorization—for certain services. Some additional information on prior authorizations is below, but always consult your plan documentation or call the customer service phone number on your Member ID card to better understand when this may apply.
When authorization is typically required (subject to plan documentation)
- All scheduled medical and surgical admissions
- Certain prescription drugs
- Out-of-network chiropractic services
- Dental implants, bone grafts/ reconstruction, orthognathic surgery
- Blepharoplasty
- Cochlear devices
- Breast surgery
- Genetic testing for breast and colon cancer
- Cancer care
- Insulin pumps
- Organ and tissue transplants
- Wheelchairs or power-operated vehicles
- Cardiac procedures and devices
- Bariatric surgery
- High tech imaging
- In-lab sleep studies
- ENT procedures
- Gender affirmation
- Pain management
- Durable medical equipment (DME) items, including: wheelchairs, power-operated vehicles, speech-generating devices, insulin pumps, bone growth stimulators and more.
- Home health
- Home infusion services
Requesting prior authorization
Your healthcare provider will submit a request for prior authorization via an electronic form, phone or fax (contact information is on the back of your member ID card). We make every attempt to process prior authorization requests within 36 hours once all clinical information is received by Blue KC.
Information needed
To ensure the authorization process is as quick and efficient as possible, we highly recommend that the physician’s office submitting requests have the following information:
- Provider name, address, tax ID and NPI
- Recent clinical information including prior tests, lab work and/or imaging performed related to this diagnosis
- Working or differential diagnosis and notes from your last visit related to the diagnosis
- Your name and address
- Type and duration of treatment performed
- Your Blue KC member ID number
When authorizations are approved
When the service has been approved, an authorization number will be provided to the ordering physician or facility. It’s the responsibility of the ordering physician or facility to complete the pre-service authorization process for your scheduled medical procedure. They can obtain verification by emailing.
IMPORTANT: Authorization from Blue KC does not guarantee claim payment. Services must be covered by your health plan and you must be eligible at the time services are rendered. Claims submitted for unauthorized procedures are subject to denial.
When authorizations are denied
Should a service be denied, Blue KC will notify the ordering physician or facility, and will contact you in writing to provide a reason for the denial and information about how you can appeal the decision.
This communication begins the appeal options per current state policy. Blue KC also offers the ordering physician a consultation with a Blue KC Medical Director, known as the peer-to-peer process. The peer-to-peer process must be initiated within 24 hours of the denial notice and completed within seven days.
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