Reminder: Preauthorization submissions via MedPolicy Blue no longer available
Please use the preauthorization tool via NaviNet® for submissions. MedPolicy Blue will still be available to access BCBSNE medical policies.
Reminder: New Claim-Denial Information Available in NaviNet
As we announced on Dec. 29, 2023, new enhanced denial messages are now available in NaviNet. This new information is intended to save your office time when checking on claim status and avoiding the need to contact Customer Service or submit claim investigations.
In NaviNet, after performing a Claim Status Search, specific denial messages will be shown for each denied claim line in Claim Status Details. Denial messages corresponding to the claim line number will be displayed directly above the Claim and Service Line Details.
The enhanced messages will provide information needed to determine next steps on the claim denial and avoid the need to reach out to Customer Service.
Our top three denial reasons are inclusive, included and duplicate. A couple of things to note:
The enhanced messaging can be reviewed on claims received after this enhancement, but also on claims received prior to this enhancement in NaviNet.
Inclusive/Included Denials. Claims denied inclusive will reference the claim number and CPT code the claim line denied inclusive to. Keep in mind, not all inclusive or included denials deny inclusive to another claim or CPT code. An example is non-billable charges. In this scenario, a message will still display advising the claim line denied inclusive, but it will not reference another claim or CPT code.
Duplicate Denials: NaviNet will advise what claim(s) the claim is denying as duplicate to. Keep in mind, if claim C denies duplicate to claim B, and claim B denies duplicate to claim A, claim C is going to show the claim # for claim B - not for the original claim A.
Exception: Non-Nebraska duplicate denials, as those are determined by the member’s plan.
Reduction in payment denial: NaviNet will show when a payment reduction has been made and the claim number/CPT code to reference when a payment reduction has been made. BCBSNE expects providers to self-serve when questioning why the full allowed amount was not used during claim processing rather than opening a claims investigation.
Reminder: Refund offsetting process for in-network providers
Blue Cross and Blue Shield of Nebraska (BCBSNE) requires a refund offsetting process for in-network providers. If you identify that a claim overpayment has been made, please follow the claims adjustment process.
Please do not send a check/payment as the recoupment will be satisfied with a refund offset.
Please reach out to our Refunds Department at 800-562-3381 with any questions.
Note: If the offset is due to an overpayment of a Federal Employee Program (FEP) claim, offsetting will only occur on other FEP claims. We will not offset overpayments on FEP claims with claims that are non-FEP.
Federal Employee Plan (FEP) Claim Inquiry Form to be decommissioned effective March 1, 2024
On Jan. 30, 2024, we advised that FEP Claims questions can now be submitted via the Claims Investigation Feature in NaviNet. With this new ability in NaviNet, the FEP Claim Inquiry Form will be decommissioned March 1, 2024.
Simply log into NaviNet, perform a Claim Status Search, and look for the “Investigate” button at the top of your Claim Status Results page. For more information on the NaviNet Claim Investigation process, please visit: NaviNet: Quick Access. If your FEP claim is not available on NaviNet, please contact our FEP Customer Service Team for assistance at 402-390-1879 or 800-223-5584.
Claim Return letters are going paperless on April 1, 2024
On Jan. 30, 2024, we posted in Happening Now that beginning April 1, 2024, Blue Cross and Blue Shield of Nebraska (BCBSNE) will no longer mail claim return letters to our participating network health care professionals and facilities for BCBSNE plans. BCBSNE will instead post them on NaviNet under Patient Documents. View the eLearning video for your reference in the Provider Academy.
If you cannot locate the letter(s), please reach out using the Claims Investigation tool explaining the steps you took in attempting to locate the letter(s) and the issue you encountered.
Multiple Procedure Adjustments for Radiology Payment: Coming the end of the first quarter of 2024
Medicare’s National Physician Fee Schedule (PFS) is a listing of CPT procedure codes sorted and ranked by their relative weight, meaning the average time a provider would take to perform the procedure, along with the expense involved in performing it. This ranking provides a recommended payment based on the relative value unit (RVU) of work. Procedures valid for Multiple Procedure Payment Reduction (MPPR) can be identified under Column S, Mult Proc, of the PFS Relative Value File.
CMS created guidelines under the MPPR to handle scenarios where multiple procedures are performed on the same patient on the same date of service. Per MPPR guidelines, multiple procedures are ranked according to RVU and paid in descending order of highest to lowest RVU. The highest-ranked procedure receives 100% payment, with the second and subsequent lower-ranked procedures receiving a reduced payment.
Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual explains, “Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often an overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work.”
BCBSNE currently aligns with CMS’s MPPR guidelines for therapy procedures and will apply the MPPR to radiology procedures the end of the first quarter of 2024. Please continue to review future issues of the Update newsletter for more information.
Resources:
CMS transmittal R3578CP
National Physician Fee Schedule Relative Value File
Changing Number of Days Auto-Approved for Inpatient Admissions
Blue Cross and Blue Shield of Nebraska utilizes InterQual criteria for hospital inpatient admission reviews, and hospitals can submit precertification requests for admissions via our online portal by signing into NaviNet. Currently, acute inpatient admissions that meet InterQual criteria and do not pend for a BCBSNE nurse to review receive an automatic approval of four days for the initial admission.
Effective June 1, 2024, the initial length of stay automatically approved for acute inpatient admissions will be reduced from four days to three days. If additional days are needed, a concurrent review request is submitted via the online portal as it is today. The number of days automatically approved for observation admissions or concurrent reviews that meet the appropriate InterQual criteria will not change.
Top three claim return reasons
To help providers submit accurate claims and take advantage of auto-adjudication, BCBSNE continues to rank the top three reasons for claim returns:
The Federal Tax Identification number (TIN) and/or the NPI number for the Provider, Rendering or Referring, is not effective for the date of service.
Please ensure you are submitting TIN/NPI of providers who are credentialed with BCBSNE. Most importantly, do not submit claims for newly-credentialed providers until you have the acceptance letter with the provider’s effective date.
For credentialing guidance, please visit NebraskaBlue.com/Credentialing or the Administrative Updates/Secure Forms link on the BCBSNE NaviNet landing page.
The provider’s name and credentials, Federal Tax Identification number and/or NPI are missing.
The required BCBS subscriber identification number is missing or invalid.
Please verify this information an resubmit your claim with the complete identification number as it appears on the member’s BCBS identification card in the correct ID number field.
It is recommended that you photocopy the patient’s member ID card at every visit to ensure you have the most up-to-date coverage information.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
InterQual and Clear Coverage are trademarks or registered trademarks of McKesson Corporation and/or one of its subsidiaries, an independent company providing services for Blue Cross and Blue Shield of Nebraska. NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.
