understanding bcbs kansas city prior authorization and precertification

BCBS Kansas City requires precertification for certain services, including surgical procedures and hospital stays. This means that patients and providers must submit a request to BCBS Kansas City before receiving these services.

Precertification is typically required for services that are considered high-cost or complex. This helps ensure that patients receive the necessary care while also controlling costs.

BCBS Kansas City has a list of services that require precertification, which can be found on their website or by contacting their customer service department.

Precertification and prior authorization serve as a checks and balances system to ensure the proper use of insurance benefits and control the risk of fraud and inappropriate use.

Precertification is a courtesy review performed by BCBSKS, which includes requests for services, supplies, or prescription drugs that have a medical policy, are high-cost, or could be deemed experimental/investigation or non-covered based on the member's contract to determine coverage.

Prior authorization is required for services performed inpatient and is used to review and approve certain medical services and treatments before they are provided.

Some examples of services that require prior authorization include home health and hospice services, ABA therapy services, transplants (with the exception of cornea and kidney), certain medications, and very high-cost drugs and therapies.

Here are some examples of prior authorization contact numbers and forms:

Note: All other drugs may be prior authorized electronically through CoverMyMeds.

To get precertification, you'll need to meet the requirements set by the health insurance company.

The patient's medical history and diagnosis are reviewed as part of the precertification process.

The healthcare provider must submit a precertification request to the insurance company within a certain timeframe, typically 1-3 business days before the procedure or treatment.

The insurance company will review the request and may request additional information or clarification from the healthcare provider.

A precertification request typically includes the patient's demographic information, diagnosis, and treatment plan.

The healthcare provider must also provide documentation supporting the medical necessity of the procedure or treatment.

Precertification and prior authorization are crucial steps in the healthcare process that help keep healthcare costs affordable for everyone. They serve as a checks and balances system to ensure the proper use of insurance benefits and prevent fraud.

Precertification is a courtesy review performed by Blue Cross Blue Shield of Kansas (BCBSKS) to determine coverage for certain services, supplies, or prescription drugs. This review is done to ensure that the service is not deemed experimental or non-covered based on the member's contract.

BCBSKS has a list of services that require prior authorization, including home health and hospice services, ABA therapy services, and certain medications. These services require a fax or email of a completed prior authorization form.

There are specific criteria for prior authorization, including ACA Prevention Copay Waiver Criteria, compounded prescriptions over $100, and germline genetic testing for hereditary breast/ovarian cancer syndrome. These criteria require a review of the request and a completed prior authorization form.

To make the prior authorization process easier, Blue KC offers an Enhanced Prior Authorization feature through their Provider Portal. This feature allows providers to submit prior authorization requests electronically and view existing requests.

If a provider is unable to get a user ID on the Blue KC Provider Portal, they can choose a fax, mail, or e-form option.

To take advantage of an easier prior authorization experience, make sure you have a Blue KC Provider Portal account. This will give you a streamlined process for submitting prior authorizations.

You can access the Blue KC Provider Portal by logging in and clicking on Prior Authorizations. From there, you'll be presented with a Disclaimer and a "Submit Prior Authorization" button if a prior authorization is needed for the code, service, or drug name you entered.

In some cases, an "Authorization Type" dropdown will display, based on if the selected code is a Medical Service for Inpatient, Outpatient, or a drug on the medical benefit. This helps guide you through the process.

You can also view existing electronic prior authorization requests by selecting Prior Authorizations and then clicking on the "View History" button. This will direct you to the Guiding Care Portal for a list of previously entered prior authorizations.

If you're unable to get a user ID on the Blue KC Provider Portal, you can click the Forms button to access our Forms page. From there, select "Submit or Review a prior authorization" to log in and enter a prior authorization electronically on the Portal.

Alternatively, you can choose to fax, mail, or use an e-form option as a last resort.

You can finalize BCBS Kansas City prior authorization with ease on any gadget. This is thanks to digital document management, which offers an eco-friendly alternative to conventional printed and signed papers.

With airSlate SignNow, you can create, modify, and electronically sign your documents promptly without interruptions. This tool is available on the airSlate SignNow Android or iOS applications.

To finalize your document, follow these steps:

By using airSlate SignNow, you can forget about lost or mislaid files, tedious browsing of forms, or mistakes that necessitate printing new copies.

Precertification and prior authorization are essentially a checks and balances system to ensure proper use of insurance benefits and prevent fraud.

These reviews help health insurance companies control the risk of fraud and inappropriate use, which ultimately keeps the cost of healthcare premiums affordable for everyone.

BCBSKS performs a courtesy review on pre-service requests to determine coverage for services, supplies, or prescription drugs that have a medical policy, are high-cost, or could be deemed experimental/investigation.

This review is particularly important for inpatient services, which require prior authorization to proceed.

The courtesy review helps BCBSKS determine if the service is covered under the member's contract, or if it's non-covered based on the contract.