2021 CMS QHP Certification Transparency in Coverage
Impacted Insurer and Plans
Insurer Name (HIOS Issuer#)
Blue Cross and Blue Shield of Kansas, Inc. (18558)
Individual Plans - Alpha Prefix (XSN)
|BlueCare EPO Gold
|BlueCare EPO Silver
|BlueCare EPO Simple Silver HDHP
|BlueCare EPO Bronze
|BlueCare EPO Simple Bronze HDHP
|BlueCare EPO Silver Plus
Out-of-network liability and balance billing
To receive benefits, a member must use a network provider. Blue Cross and Blue Shield of Kansas contracts do not provide benefits when services are provided by an out-of-network provider, unless due to a medical emergency or if a covered service cannot be performed by an in-network provider. In cases where benefits are allowed by an out-of-network provider, the amount above our allowance will be the member's responsibility and may be billed by the provider.
Balance billing refers to instances where a non-contracting provider bills a member for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill the member for the remaining $30. A contracting provider may not balance bill a member for covered services.
Member claims submission
In-network providers have an obligation to file claims on a member's behalf. In the event a member has services provided by an out-of-network provider and the provider is unwilling to file a claim, a member may file a claim by completing a Member Claim Form, attaching a copy of the provider's invoice and mailing it to the address below. The member may access the Forms section of this website to obtain the correct claim form. The provider's invoice must be an itemized bill to include the patient’s name, the service provided, service date, cost for each service, diagnosis, and the provider’s name and tax ID number. The member must complete a separate claim form in full for each hospital and/or doctor bill being submitted. For filing prescription drug claims, the member must file one claim per patient, attach an itemized bill from the pharmacy with the pharmacist’s signature or the pharmacy receipts and mail it to the address below. The member should not send cash register receipts. The proof of service must include the patient’s name, prescription name, and prescription Rx number, National Drug Code, quantity, number of days supply, service date, cost for each prescription plus the complete name and address of the pharmacy, and the pharmacy tax ID number.
The claim must be received by Blue Cross and Blue Shield of Kansas within one year and 90 days from the date the services were rendered. To inquire about a claim a member has submitted, a member may contact Customer Service at 800-432-3990.
Submission via postal mail:
Blue Cross and Blue Shield of Kansas
1133 SW Topeka Blvd.
Topeka, Kansas 66629
Grace periods and claims pending policies during the grace period
Blue Cross and Blue Shield of Kansas is a pre-paid health insurance issuer and a member's premiums are due on the first of each month. A member's contract does have a 10 day grace period, which means a premium not paid on or before its due date may be paid in the 10 days that follow. During the grace period this contract will stay in force, however if premiums are not paid by the end of the grace period, the contract will be canceled effective the first of the month when the premium was due.
For members receiving advance payments of the premium tax credit, this contract has a 90 day grace period, which means that if a premium is not paid on or before its due date, it may be paid during the 90 days that follow.
During the grace period, this contract will stay in force; however claims will only be paid during the first month of the grace period. Following the first month, claims will be pended until payment has been received. The claim(s) will be held to await processing until premiums are paid. If premiums are not paid by the end of the grace period, this contract will be canceled 30 days following the original due date and pended claims will be denied. The member will be responsible for denied claims.
There may be situations where Blue Cross and Blue Shield of Kansas reprocesses a claim which causes financial responsibility to change for the provider or member. This can be due to a provider submitting a correction to the original claim or due to discovery of a claim paid incorrectly. In some cases, claims could be paid during a grace period and then denied retroactively if premiums are not received. By paying premiums on time, a member can avoid these situations.
Member recoupment of overpayments
If a member's premium is adjusted due to an over billing and no refund is requested by the member, the insurer will apply the credit toward future premiums (for the same year only) until the overpayment is offset. If a refund is a requested, it will be issued to the member within 7 to 21 days of the request. To request a refund, a member may contact Customer Service via phone at 800-432-3990, via email at [email protected] or via postal mail at:
Blue Cross and Blue Shield of Kansas
1133 SW Topeka Blvd.
Topeka, Kansas 66629
Medical necessity and prior authorization time frames and member responsibilities
A Blue Cross and Blue Shield of Kansas member contract requires prior authorization for inpatient admissions, Skilled Nursing, hospice, high-dose chemotherapy, transplants, temporomandibular joint dysfunction, some prescription drugs, and specific services for pediatric vision and pediatric dental.
Blue Cross and Blue Shield of Kansas will authorize coverage if medical necessity is supported. A member or their provider must allow 15 days before the service to process standard prior authorization requests. Urgent prior authorization requests will be processed within 72 hours. Failure to obtain prior authorization may result in non-covered services. A member or their provider must request a prior authorization 72 hours in advance of a planned inpatient admission. If not requested, only the portion of the inpatient claim that would normally be payable if services were received as an outpatient will be covered.
Additional information regarding medical necessity and prior authorization can be found in the member contract.
Drug exceptions time frames and member responsibilities
A member or provider may request an exception to permit coverage for a clinically appropriate drug excluded from the formulary by completing the Request for Prescription Drug Coverage Exception. This form includes the reason(s) for the request, including an attestation that ALL otherwise clinically appropriate alternative drugs on the formulary are contraindicated for the member, have caused the member to experience an adverse reaction, and/or have been unsuccessful in treating the member's condition. Medical records may be requested to demonstrate the medical need for the excluded drug. Once all necessary information is received, the issuer will make a determination and notify the person who made the request with a decision within 72 hours. If the member is suffering from a health condition that may seriously jeopardize the member's life, health, ability to regain maximum function, or if the member is currently undergoing a course of treatment using the requested excluded drug, the member may request the review to be expedited and a decision will be made within 24 hours.
If the member's request is denied, the member has the right to request an external review of the decision by an independent review organization (IRO). To exercise this right, the member must submit the request for external review to the insurer in writing. The insurer will send the request to the IRO. The member will be notified of the IRO's decision within 72 hours (or 24 hours if under exigent circumstances) of the receipt of the member's request. If the exception is denied, the decision is final.
Information on Explanations of Benefits (EOBs)
An Explanation of Benefits (EOB) is a summary sent to the member to help explain how a member's claim is processed. It shows how much the insurer paid, what the member's financial responsibility may be, and any provider write-offs. An EOB is sent to the member each time a claim is finalized.
How a consumer should read and understand the EOB.
Coordination of benefits (COB)
Coordination of benefits (COB) is the practice of ensuring that insurance claims are not paid multiple times when a member is covered by two health plans at the same time. The idea behind COB is to ensure the payments of both plans do not exceed 100 percent of the covered charges. The COB provision coordinates the health care benefits in the order in which the multiple health plans must pay benefits. Under a COB provision, insurance companies share the burden without overpaying. COB determines which plan is primary and which is secondary. The primary plan will pay the claims first and the unpaid balance will be paid by the secondary plan to the limit of its responsibility. Benefits are coordinated between the two health plans to ensure that the member receives full coverage.
End 2021 CMS QHP Certification Transparency in Coverage