Transparency in Coverage

2025 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)

Out-of-network liability and balance billing

Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with a member’s plan. Blue Cross and Blue Shield of Kansas will only pay for out-of-network benefits when services are due to a medical emergency or if a covered service cannot be performed by an in-network provider. Depending on the health care professional, the service could cost more or not be paid for at all by the plan. This cost is the member’s responsibility and charging this extra amount is called balance billing. 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 out-of-network provider may bill the member for the remaining $30. Balance billing may be waived for emergency services received at an out-of-network facility. An in-network provider may not balance bill a member for covered services.

Member claims submission

A claim is a request to an insurance company for payment of health care services. 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 the following steps:

1. Complete this claim form for all services, including prescriptions.
2. Attach an itemized bill from the provider for the covered service.
3. Make a copy for your records.
4. Mail your claim to the address below:

Blue Cross and Blue Shield of Kansas
1133 SW Topeka Blvd.
Topeka, KS 66629-001

The claim must be received by Blue Cross and Blue Shield of Kansas within one year and 90 days from when you received the service. To inquire about a claim a member has submitted, or ask questions, you may contact customer service at 800-432-3990.

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 90 day 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.

Retroactive denials

A retroactive denial is the reversal of a claim Blue Cross and Blue Shield of Kansas has already paid. If we retroactively deny a claim that had been previously paid for a member, the member will be responsible for payment. Some reasons a member may have a retroactive denial are: a provider submitting a correction to the original claim; a claim paid during the second or third month of a 90 day grace period; or having a claim paid for a service for which they were not eligible. Members can avoid retroactive denials by paying premiums on time and in full. Members can also make sure they use in-network providers and ask if the service performed is a covered benefit.

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, KS 66629-001

Medical necessity and prior authorization time frames and member responsibilities

A prior authorization or preservice review is when Blue Cross and Blue Shield of Kansas approves services before a member receives them. If a member does not get a prior authorization when it is required, the member may have to pay the full cost of the care. Blue Cross and Blue Shield of Kansas member contracts require 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

Sometimes our BlueCare members need access to drugs that are not listed on the plan's formulary (drug list). 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.

Initial Exception Review

• For initial standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request.
• For initial expedited exception review of medical requests, the timeframe for review is 24 hours from when we receive the request.

External Review

If the drug exception is denied, an external review of the decision can be made by an independent review organization (IRO).

• For external review of standard exception requests that were initially denied, the timeframe for review is 72 hours from when we receive the request.
• For external review of expedited exception requests that were initially denied, the timeframe for review is 24 hours from when we receive the request.
• To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form.

An external review may be requested by a member, member's representative, or prescribing provider in writing by email, fax, or mail. Whether denied or approved, the decision is final and BCBSKS must follow the IRO's decision. Requests can be sent to:

• Email Address: [email protected]
• Fax Number: 785-290-0785
• Mailing Address:

Blue Cross and Blue Shield of Kansas
Special Services
1133 SW Topeka Blvd.
Topeka, KS 66606-001

Information on Explanations of Benefits (EOBs)

An Explanation of Benefits (EOB) is a summary sent to the member to help explain how each claim is paid on behalf of a member. An EOB is sent after Blue Cross and Blue Shield processes a claim, and multiple claims can be present on one EOB. It shows the date of service, what the provider billed, what the provider was paid, any provider write-offs, and what the member’s financial responsibility may be. The EOB sent does not show the service(s) provided and it is not a bill. Whenever you receive an EOB, review it closely and compare it to any statements from the provider. 

How a consumer should read and understand the EOB.

Coordination of Benefits

Coordination of benefits (COB) is when a member is covered under one or more other group or individual plans, such as one sponsored by a spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about coordination of benefits can be found in your member contract.

End 2025 CMS QHP Certification Transparency in Coverage