What you need to know about prior authorizations
Blue KC wants you to receive the most effective, appropriate care and 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, medical procedures, and medications.
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 Blue KC member ID card).
NOTE: If you have pharmacy coverage through Blue KC, your physician must submit prior authorization requests for prescription drugs via electronic form.
Your physician’s office will submit:
- 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
- Type and duration of treatment performed
- Your name and address
- Your Blue KC member ID number
- Provider’s name, address, tax ID and NPI
When Authorizations are Approved
Once the medical procedure has been approved, Blue KC will fax an authorization number, or a call the ordering physician or facility.
It’s the ordering physician or facility’s responsibility to complete the authorization process for your scheduled medical procedure. They can obtain verification by emailing firstname.lastname@example.org.
IMPORTANT: Blue KC authorization does not guarantee claim payment. Services must be covered by your health plan, and you must be eligible at the time services are received. Claims submitted for unauthorized procedures are subject to denial.
When Authorizations are Denied
Blue KC will notify the ordering physician or facility via fax and contact you in writing if the authorization is denied. We will 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.
Following are some common questions regarding the Prior Authorization process:
1. How do I know what procedures require prior authorization?
Visit your member portal at MyBlueKC.com, click on Plan Benefits in the left column, then Prior Authorization for a complete list of procedures, products, services and medications that require prior authorization. You can also refer to your Medical Benefits Booklet in the Plan Benefits section of your member portal at MyBlueKC.com.
2. Most of the tasks involving prior authorization seem to fall on the provider and insurance company. What’s my role?
You can do your part by knowing what procedures, products, services, and medications require prior authorization, and confirming your provider has the correct information to submit on your behalf.
3. Where can I find the status of a prior authorization?
Log in to your member portal at MyBlueKC.com, click on Plan Benefits in the left column, then Prior Authorization. The Authorization status tab includes details on prior authorizations requested over the past 24 months.
4. If my prior authorization request is approved, will Blue KC cover the costs?
Your coverage and plan payment are subject to your benefits and eligibility. Coinsurances, copayments, and deductibles may apply. Review your Medical Benefits Booklet at MyBlueKC.com, click on Plan Benefits in the left column, then Medical, or call Customer Service at the phone number on your Blue KC member ID card to verify your coverage.
5. What if my prior authorization is denied?
Refer to your denial letter for next steps. Your provider may be able to conduct a peer-to-peer discussion. You, your provider or your designated representative may also be able to appeal.
6. When do I need approval for hospitalization?
All scheduled medical and surgical hospital admissions must receive prior authorizations.