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.
Frequently asked questions
Get clear answers about when and why prior authorizations are needed, how to request them and what to expect during the process.
Prior Authorization
Log in to your member account to reach Prior Authorization and view Blue KC’s typical process and timeline for prior authorizations. This may vary.
All scheduled medical and surgical hospital admissions must receive prior authorizations.
If you have any questions, contact the Blue KC Prior Authorization team at 816-395-3989 or 1-800-892-6116. Or call the Blue KC Customer Service number on your member ID Card.
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.
Your coverage and plan payment are subject to your benefits and eligibility. Coinsurances, copayments, and deductibles may apply. Review your Medical Benefits Booklet in your member account Plan Benefits, or call Customer Service at the phone number on your Blue KC member ID card to verify your coverage.
If you don’t see a request in your member account or need to obtain details about an authorization from over a year ago, please contact our Customer Service team using the phone number listed on your member ID card.
Log in to your member account to reach Prior Authorization. The Request History tab includes details on prior authorizations requested over the past 24 months.
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.
Log in to your member account to reach 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 your Plan Benefits.
Some procedures, equipment purchases, and medications require that your doctor collaborate with Blue KC clinicians to ensure you receive care and treatment that is both safe and affordable. When necessary, your doctor will send Blue KC a request for authorization that outlines the care you need and includes your medical records. If approved, your doctor will guide you through the next steps in your care journey and / or send a prescription order to your preferred pharmacy.
To review prior authorizations for medications, please log in to your member portal. From the menu select the option for Prior Authorization and Step Therapy. You will see directions on how to access this information from the Optum Rx site.
Prior authorization (PA) means you must get approval before your plan will cover your medication. PA is used to make sure the medication you’re taking is appropriate and effective for your condition. To start the prior authorization process, your doctor can access BlueKC.com. Your doctor will need to provide more information about why you are taking a medication.
Log in to your member account to reach Prior Authorization and view Blue KC’s typical process and timeline for prior authorizations. This may vary.
All scheduled medical and surgical hospital admissions must receive prior authorizations.
If you have any questions, contact the Blue KC Prior Authorization team at 816-395-3989 or 1-800-892-6116. Or call the Blue KC Customer Service number on your member ID Card.
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.
Your coverage and plan payment are subject to your benefits and eligibility. Coinsurances, copayments, and deductibles may apply. Review your Medical Benefits Booklet in your member account Plan Benefits, or call Customer Service at the phone number on your Blue KC member ID card to verify your coverage.
If you don’t see a request in your member account or need to obtain details about an authorization from over a year ago, please contact our Customer Service team using the phone number listed on your member ID card.
Log in to your member account to reach Prior Authorization. The Request History tab includes details on prior authorizations requested over the past 24 months.
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.
Log in to your member account to reach 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 your Plan Benefits.
Some procedures, equipment purchases, and medications require that your doctor collaborate with Blue KC clinicians to ensure you receive care and treatment that is both safe and affordable. When necessary, your doctor will send Blue KC a request for authorization that outlines the care you need and includes your medical records. If approved, your doctor will guide you through the next steps in your care journey and / or send a prescription order to your preferred pharmacy.
To review prior authorizations for medications, please log in to your member portal. From the menu select the option for Prior Authorization and Step Therapy. You will see directions on how to access this information from the Optum Rx site.
Prior authorization (PA) means you must get approval before your plan will cover your medication. PA is used to make sure the medication you’re taking is appropriate and effective for your condition. To start the prior authorization process, your doctor can access BlueKC.com. Your doctor will need to provide more information about why you are taking a medication.
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