Claims Payment Policies and Other Information:
Blue KC understands the importance of providing access to useful information about your coverage so that our members are able to make informed decisions. Below is a link for you to understand an overview of our claims payment and other helpful policies:
Coverage Terms & Processes:
As a healthcare consumer, it’s important you know and understand the various terms and processes used in health insurance. The following provides an overview of coverage terms and processes, as required by the Centers for Medicaid Services (CMS).
Machine-Readable Files:
The Transparency in Coverage Final Rule, issued on Nov. 12, 2020, sets forth requirements for group health plans and health insurance issues to produce machine-readable files (MRFs) that disclose in-network negotiated rates and historical out-of-network allowed amounts by July 1, 2022.
Prior Authorization Metrics for Medical Items and Services (excluding drugs):
To comply with the CMS Interoperability and Prior Authorization final rule, Blue Cross and Blue Shield of Kansas City (Blue KC) is required to annually report aggregated prior authorization metrics. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers.