Provider Responsibility
FAQs
1. What is my primary responsibility when treating Blue KC members?
As a provider, you are solely responsible for all medical decisions, care, and treatment. Blue KC does not dictate clinical methods or influence medical judgment.
2. Does Blue KC assume liability for how I treat patients?
No. Blue KC is not liable for treatment methods, medical risks, or the selection of alternative therapies. All care decisions are the responsibility of the provider.
3. Do I need to see the patient in person to bill for services?
You may see members in-office or via telehealth, but the visit must include supporting documentation of the encounter to establish a physician–patient relationship and justify billing.
4. Can Blue KC deny payment for certain services?
Yes. Blue KC may deny reimbursement if services are deemed not medically necessary, not covered, or not provided in accordance with the Provider Agreement.
5. Am I required to treat the member even if Blue KC denies a claim?
Yes. Providers are expected to deliver appropriate care under relevant laws and professional standards, regardless of Blue KC’s claim decisions or utilization review outcomes.
6. What types of utilization review processes should I be aware of?
Providers must comply with:
- Prior Authorization (pre-service review)
- Concurrent Review (during active treatment)
- Retrospective Review (post-treatment)
- Case Management (for complex care coordination)
- Quality Improvement (ongoing outcomes tracking)
7. What happens if I don’t comply with utilization review requests?
Failure to submit timely medical records or participate in reviews may result in denial of reimbursement, including appeals and grievances governed by Blue KC and applicable law.
8. Does Blue KC’s decision during utilization review limit my clinical responsibilities?
No. Even if Blue KC denies coverage, providers are still required to provide care that complies with legal, ethical, and professional standards of practice.
9. What should I include in documentation for utilization reviews?
Submit accurate, timely, and complete medical records supporting the necessity, scope, and delivery of services requested or provided.
10. Do these requirements apply to all benefit plans I participate in?
Yes. These responsibilities apply to all Benefit Plans, including those not directly administered by Blue KC, where Blue KC is acting on behalf of another Blues plan.
Provider is solely responsible for patient medical decisions, care and treatment. Blue KC shall not be liable for or exercise control over the methods used by Provider in regards to the nature of treatment, risks or alternatives or the availability of other therapy, consultation or test.
Providers must evaluate each member in office or through telehealth with supporting documentation of encounter to bill services, thus establishing a physician-patient relationship. Blue KC may deny payment for healthcare services which it deems as not medically necessary, are not services or are not provided in accordance with the Provider Agreement.
Regardless of any actions taken by Blue KC within the Utilization Review process, including denial of a claim, providers are obligated to provide appropriate services to members under applicable laws and any code of professional responsibility.
Utilization Review, Appeals and Grievances
Providers need to provide timely medical records as requested and understand all aspects of the Utilization Review:
- Prior Authorization – prior review of services including: all inpatient stays that are medically necessary as well as services and supplies
- Quality Improvement – the process and outcomes of member services to ensure care is efficacious and consistent with generally accepted medical practices
- Concurrent Review – review of the medical necessity of healthcare services
- Case Management – coordination and healthcare assistance and monitoring
- Respective Review – review after the patient has received healthcare to assess reimbursement levels, consistency and adjudication
Failure to comply may result in denial of reimbursement for services. This includes the appeals and grievance procedures prescribed by Blue KC and by state and federal law. This applies for any Benefit Plan, even ones that aren’t administered by Blue KC.