Blue KC Coverage Criteria
Latest Blue KC coverage criteria updates14
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Diabetes Mellitus Testing (FPG, OGTT, A1c)Coverage and medical necessity criteria for diagnostic and screening laboratory testing for diabetes mellitus (fasting plasma glucose, oral glucose tolerance test, and hemoglobin A1c) for Blue KC members and providers.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Diagnostic Testing of Common Sexually Transmitted InfectionsDefines reimbursement and coverage criteria for diagnostic laboratory testing for common STIs (C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis and selected others) for Blue KC lines of business and provider types.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseDefines reimbursement policy for serum multianalyte assays with algorithmic analysis and individual serum biomarkers used to evaluate or monitor hepatic fibrosis in chronic liver disease across Blue KC product lines. Specifies which proprietary tests may be reimbursed (FibroSURE/FibroTest, ELF/FibroTest) under certain clinical contexts and lists biomarkers/tests that do not meet coverage criteria.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Urine Culture Testing for BacteriaDefines coverage criteria for urine culture testing (including isolate identification and antibiotic susceptibilities) for diagnosing and managing urinary tract infections and bacteriuria for Blue KC members and applicable provider types.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01General Inflammation Testing (CRP and ESR) Coverage CriteriaPolicy governing reimbursement and preferred use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing for diagnosed or suspected inflammatory conditions for Blue KC lines of business and provider types specified.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Helicobacter pylori Testing (Coverage Criteria)All Blue KC updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Payment Integrity Compliance — Hepatitis TestingDefines Blue KC's payment integrity and reimbursement rules for hepatitis A, B, C, and D diagnostic testing across impacted provider types and lines of business. Applies to claims adjudication and reimbursement decisions for covered members based on benefit coverage and clinical criteria.All Blue KC updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Payment Integrity Compliance — Prescription Medication and Illicit Drug Testing in the Outpatient SettingDefines Blue KC's coverage criteria and coding guidance for outpatient clinical toxicology (presumptive and definitive drug testing) for prescription medication and illicit drug testing; applies to professional and facility providers across commercial and Medicare Advantage lines of business.All Blue KC updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Therapeutic Drug Monitoring for 5‑FluorouracilThis payment policy governs reimbursement decisions for therapeutic drug monitoring used to manage dose adjustment of 5‑fluorouracil and specifies tests that do not meet coverage criteria; it applies to providers and facilities submitting claims to Blue KC across commercial and Medicare Advantage lines of business.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Blue KC Prescription Drug List (PDL) and Pharmacy Services Coverage CriteriaGoverns pharmacy benefit management for Blue KC HMO, PPO and EPO members with a prescription drug benefit, including PDL use, prior authorization, quantity limits, step therapy, specialty pharmacy processes and member/provider resources.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Prescription Drug List (PDL) and Pharmacy Services — Coverage CriteriaDefines the Prescription Drug List (PDL), pharmacy benefit management, prior authorization and utilization management processes, specialty pharmacy requirements, and member/provider resources for Blue KC members with a prescription drug benefit.All Blue KC updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Prescription Drug List (PDL) — Pharmacy Utilization Management and Coverage CriteriaGoverns the Prescription Drug List (PDL), prior authorization, tiering, quantity limits, step therapy, specialty pharmacy use, and related pharmacy benefit processes for Blue KC members with a prescription drug benefit. Affects prescribers, pharmacists, and covered HMO, PPO, and EPO members.All Blue KC updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2020-11-01Proton Beam Therapy reimbursementDefines Blue KC's payment approach for proton beam therapy, who is affected (professional and facility providers across multiple commercial lines and Medicare Advantage), and references clinical indications to MCG medical necessity criteria.All Blue KC updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2020-09-01Critical Care ServicesThis payment policy defines when and how critical care services (CPT 99291, 99292) are reported and reimbursed by Blue KC, including time reporting rules, services included in critical care, split/shared visits, and scenarios that may not qualify; it applies to professional providers across Blue KC lines of business.All Blue KC updates
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Tool Description
Search Blue KC coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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