To help providers submit accurate claims and take advantage of auto-adjudication, Blue Cross and Blue Shield of Nebraska (BCBSNE) continues to rank the top three reasons for claim returns:
The Federal Tax Identification number 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 (TIN) number and/or NPI are missing.
Modifier is missing, not legible or is invalid for the procedure code.
Please be sure to add the appropriate modifiers as this additional information helps to make sure your claim gets paid correctly for the services rendered.
Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code. They are used to add information or change the description of service to improve accuracy or specificity. Keep in mind that the use of modifiers should always follow the guidelines set by the American Medical Association (AMA) and other relevant coding authorities.
Turn-around time on CAQH updates
Demographic changes will be updated in the provider directory within 48 hours from submission. Please allow up to 30 days for taxonomy, NPI, provider type and location updates. New taxonomies will be prioritized if recredentialing is needed.
To support self-service and timely updates, our teams, Health Network Requests, Provider Executives and Customer Service, will direct providers to make their updates through CAQH. You will need to utilize the steps to update CAQH appropriately.
When adding/updating information in CAQH, please ensure that you always include:
Tax ID
Type II NPI
Directory name
Address, city, state, ZIP code
Email address (for contracting purposes so we can reach directly out to you for needed paperwork)
Effective date
Reminder: Taxonomy code requirement
Did you know? When submitting a claim, the correct provider taxonomy must be on the claim for it to process. This is the taxonomy you were credentialed with and could be different from NPPES. Please see Claims FAQs on our Provider Academy.
What is provider taxonomy? Provider taxonomy is a set of 10 alphanumeric characters that define specific specialty categories for providers (individual, group, or institution). There are different levels defined in the code set, including Provider Grouping, Classification and Area of Specialization. Providers may identify under more than one code set.
How does this affect you? Please ensure you are submitting the correct taxonomy. This information is needed for credentialing, delegated updates, and claims processing. It is important that the taxonomy matches the credentialed taxonomy on file with BCBSNE. When the appropriate information is not submitted, the claim will be returned.
For newly credentialed providers, please reference your letter with effective date and taxonomy code listed. An excellent source for more information on taxonomy is NUCC.org.
Medicare Advantage (MA) claims
When submitting Medicare Advantage claims, CMS standards must be followed to prevent unnecessary returns and processing delays. Beginning June 5, 2024, with the CMS edits in place you will see non-Nebraska MA claims process more appropriately.
At this time, please do not submit Reconsideration Requests for claims you believe did not pay correctly. We will be running reports to determine if adjustments or recoupments are needed. Once we have made that determination, in alignment with contractual language, we will post a notification on Happening Now.
Reminder, claim return letters are now available in Plan Documents on NaviNet®.
G0109 (Group Diabetic Education) will be added to our telehealth policy effective July 1, 2024
G0109 follows the same guidelines as other telehealth codes and requires modifier 95 with a place of service 02 or 10. In addition, the service must be billed by an approved telehealth provider.
Denials for non-FDA approved treatments
BCBSNE has made the business decision to not cover Q0224 & M0224. While these drugs had received emergency use authorization, these drugs are not FDA approved. Additionally, any drug or service that is not FDA approved will be denied by BCBSNE as benefit plans do not provide coverage. Claims submitted would deny as provider liability.
EAPG Providers
BCBSNE is making changes to the way our EAPG edits occur. Unforeseen impacts of having NCCI edits coupled with EAPG edits with NCCI built in caused impacts to the claims pricing.
This has been corrected and system edits have been completed. NCCI edits, in addition to the EAPG edits, are now appropriately pricing claims without the need for manual intervention. Claims are processing faster, and reconsiderations no longer need to be sent for payment adjustments. For you, our provider, this means increased accuracy and faster turnaround times.
Reconsideration vs Timely Filing
Please ensure you are using the reconsideration form rather than a timely filing override request for requests pertaining to coordination of benefits (COB), workers’ compensation, and subrogation adjustments.
As a reminder, effective Jan. 1, 2024, BCBSNE is no longer working or returning incorrectly filed timely filing requests. If your request was filed incorrectly, please submit using the correct form.
Example scenario: If you are notified by another carrier that a member’s Blue Cross and Blue Shield insurance is primary, you should submit a reconsideration form with the primary recoupment or denial.
Reminder: Reconsideration and Appeal letters are now paperless
Starting on April 1, 2024, claim return letters to our participating network health care professionals and facilities were available exclusively online. On May 15, 2024, the Reconsideration and Appeal letters were added to this paperless process.
For your convenience, these letters are available on NaviNet under patient documents. For more information on accessing patient documents in NaviNet see our eLearning video.
If you cannot locate the letter(s), please reach out using the Claims Investigation tool explaining what you did to locate the letter(s) and the issue you encountered.
NaviNet® - What is it and why should I use it
NaviNet is an easy-to-use, secure portal that links you, our provider to us, BCBSNE. With NaviNet web-based solutions we can share critical administrative, financial, and clinical data in one place.
This tool helps you manage patient care with quick access to:
Verify member eligibility
Request an authorization
Request preservice review for out-of-area members
View claim and payment details
View documents
Investigate and follow-up on claim investigations
Appeal a claim and view existing appeals
Access remittance advice details
Access fee schedules
View claim return letters
Review your provider information
For written instructions on how to access the information above, please download our NaviNet Guide on our NaviNet Quick Access webpage.
If you prefer eLearning video tutorials with step-by-step instructions these are available in our Provider Academy. Visit NaviNet Quick Access for FAQs for our most commonly asked questions to improve your self-service experience.
NaviNet helps speed up the provider-health plan connection and can often replace paper transactions. If you are not a NaviNet user, learn more about NaviNet.
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They can sign up to receive an email when a new edition of Provider Update and Provider Bulletin have been added to our Alerts and Updates page.
You are receiving this because you are identified as a provider 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.
