BlueSpeak June 2026: Provider Education

IMMEDIATE ACTIONS: (1) Billing team must ensure all secondary payer EOB documentation is submitted to Blue KC for claim processing, including cases where the other carrier denies coverage. (2) Providers must update documentation templates to follow DSP format (Diagnosis-Status-Plan) with specific ICD-10-CM coding, ensuring all chronic conditions and conditions impacting care are documented. (3) Coding staff must review and implement corrections for the Top 5 miscoded conditions: ensure diagnoses are documented in encounter notes with clinical rationale, include status (stable/worsening/resolved), move relevant PMH items to active assessment/plan, confirm definitive diagnoses, and clearly distinguish active vs. historical conditions. (4) Care coordinators and front desk must implement protocols to ensure patients attend follow-up appointments and complete preventive services, with emphasis on medication adherence tracking. DEADLINE - By June 30, 2026: (5) Billing team must establish prepay audit workflow for claims with $1M+ allowances, including procedures to submit itemized bills and medical records to fax 816-926-4258 per BCBS requirements, and implement DRG, pricing, payment policy, and never event reviews. (6) Billing staff must begin using the enhanced Claim Inquiry e-form (accessed via Providers.BlueKC.com login) for all inquiries (denials, overpayments, prior auth denials, medical records requests, etc.) instead of faxing without the form. ONGOING: (7) Referring providers submitting lab orders must include complete and accurate diagnosis codes with valid modifiers to prevent clinical edit denials; ensure labs receive this information at time of order since independent labs cannot modify diagnosis codes themselves. Failure to submit proper documentation will result in claim denials and payment delays.