Exciting partnership with Cotiviti for enhanced payment accuracy
In our September 2024 Provider Update, we proudly reaffirmed our commitment to achieving greater payment accuracy. Building on this promise, we announced our partnership with Cotiviti in April 2025, as shared on Happening Now and NaviNet® Plan Central.
Starting in May 2025, Cotiviti will conduct periodic post-payment reviews of paid medical claims, including Clinical Claim Validation (CCV). This collaboration will enhance our efforts to ensure accuracy and efficiency, leveraging the expertise of our new vendor.
What you can expect
CCV reviews are designed to ensure proper billing practices and promote accuracy and fairness. These reviews may require a copy of the medical records, which will be requested if Blue Cross and Blue Shield of Nebraska (BCBSNE) has not already received them. BCBSNE and Cotiviti are collaborating to minimize the number of medical record requests to providers, streamlining the process for your convenience.
If a claim is selected for review, you will receive a letter identifying the claim(s) and providing detailed information on the guidelines and timeframes to follow. Please note, the historical lookback period follows our contractual timeframe, which is typically 12 months. Currently, the reviews include Local, Host and Federal Employment Program claims.
About Cotiviti
Cotiviti’s team comprises registered nurses, medical and claims experts with extensive expertise in coding, claims operations and quality. They work closely with clients and medical providers to develop effective strategies, plans and activities that prevent future payment errors and enhance the reimbursement process. Cotiviti is a recognized leader in the industry, partnering with health plans across the United States.
Cotiviti is a Business Associate of BCBSNE as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will perform its responsibilities on behalf of BCBSNE in full compliance with HIPAA requirements.
Your cooperation is valued
We appreciate your assistance in providing Cotiviti’s staff with access to the necessary medical and/or financial information to complete these reviews. These requests will be consistent with the methods previously used by BCBSNE, including mail, fax and EMR access.
Thank you for your anticipated cooperation. Please share this information with your staff as you deem appropriate.
Blue Goes Green: Transition to fillable online forms
As we announced last month on Happening Now, downloadable versions of online forms are no longer available for you to print and mail to us. This change helps reduce paper waste and improve digital accessibility.
Why the change?
Efficiency: Fillable forms can be completed and submitted online, saving time and reducing errors.
Faster processing: Online submissions are processed more quickly.
Accessibility: Fillable forms are user-friendly and easy to complete.
What providers need to know:
Access: Fillable forms are available on our website.
Support: Our team is here to help with any questions.
Thank you for supporting our Blue Goes Green initiative.
Should I submit an appeal or reconsideration request?
What is a reconsideration request?
A reconsideration request is used to review the reimbursement level of submitted charges. This is only available if a claim has been processed and remittance advice issued.
When should I submit a reconsideration request?
Submit a reconsideration request for:
Out-of-network providers: Submit via NaviNet or find the reconsideration form on our Provider Forms page
Complete the form fully, including claim number and member ID
Check the applicable box and describe the issue concisely
Include relevant documentation only
What is an appeal?
An appeal is a request to review a denial that you disagree with. Examples include medical necessity, medical policy and investigational determinations.
What is considered an appeal review?
Appeal reviews include:
Medical necessity
Investigative
Cosmetic
Contract exclusions
Duplicate
High-dollar prepayment review
No preauthorization obtained
Pre-existing conditions
Medical emergency
Medical vs. dental
In-network vs. out-of-network
How do I submit an appeal?
Submit appeals, timely filing requests and reconsiderations via NaviNet. Forms for out-of-network providers are available on our Provider Forms page.
Advanced Provider Inquiry case closure
When an Advanced Provider Inquiry is resolved, the case will be closed. You will receive an email notification indicating its closure. If you have any further follow-up questions, please submit a new API request. Responses will not be provided to closed cases.
Upcoming change in medical policy III.219: Preauthorization requirement for biventricular pacemaker with and without ICD
We announced earlier this month that effective Aug. 1, 2025, medical policy III.219, concerning biventricular pacemaker with and without ICD will undergo significant change. Procedure code 33249 will now require preauthorization regardless of whether the ICD is dual or single chamber.
This policy update aims to ensure that all patients receive appropriate and necessary care while maintaining the integrity of the health care system. Providers are encouraged to familiarize themselves with the preauthorization requirements to avoid any disruptions in patient care.
For further information and detailed guidelines, please refer to the updated medical policy.
Coming soon: Changes to submit appeals, timely filing requests and reconsiderations via NaviNet
Starting soon, providers will notice a streamlined process for submitting appeals, timely filing requests and reconsiderations via NaviNet. The current system, which requires selecting a “type” (Appeal, Recon or Timely Filing), will be replaced with a “reason” dropdown menu.
New submission process
Step 1: Go to your claim status details.
Step 2: Click on the Appeal button and select the reason for your request.
Step 3: Add free-form text, attach any supporting documentation (in PDF format) and submit the request.
These changes aim to simplify the submission process and improve efficiency. Stay tuned for more updates and ensure you are familiar with the new system to make the transition smooth.
Reminder: Status of preauthorization and requirements
We have noticed an increase in faxes requesting the status of preauthorization reviews. This is unnecessary and is impacting the efficiency of our fax system. To streamline the process, please follow the steps below to check the status of your preauthorization requests.
Checking status via NaviNet
To check the status of a preauthorization request submitted via NaviNet, please follow these steps:
Log in to NaviNet.
Under Workflows for this Plan, select Preauthorization or Precertification.
Select the ordering provider and click the submit button. Note: The rendering facility will be able to view the status only if the ordering provider identified the rendering facility when entering the request in NaviNet.
Click the Authorization List icon from the menu on the left side of the screen to view the authorizations.
For preauthorization requirements Reminder: To verify if preauthorization is required for a specific procedure code you must utilize the medical policy tool.
Out of area members
For out of area members, please select Pre-Service Review for Out of Area Members Workflows.
Additional help
If your preauthorization request was initially faxed in, you may contact Customer Service at 800-635-0579, Option 5.
By following these steps, you can efficiently check the status of your preauthorization requests, reduce the number of unnecessary faxes and verify Medical Policies. Thank you for your cooperation.
Alert: Review your demographic data in CAQH every 90 days
As a reminder, the Consolidated Appropriations Act (CAA) requires that certain provider directory information be verified every 90 days. BCBSNE participating providers are required to verify and attest to the accuracy of their information in the CAQH Provider Data Portal. The information must be attested to every 90 days, even if the data has not changed since it was last verified.
Under the CAA, BCBSNE is required to remove providers from our directory whose data we are unable to verify. If you do not complete the attestation in CAQH, and we are unable to verify your information, you may be removed from the directory.
For more information about verifying your information in CAQH, please visit CAQH Provider Data Portal.
Beginning Aug. 1, 2025, BCBSNE MA claims for readmissions will follow the Centers for Medicare & Medicaid Services guidelines denying the second readmission. A detailed MA procedure will be published by June 1, 2025.
TriWest is experiencing an ongoing issue affecting remittances and is currently at the highest level of escalation.
There is currently no estimated time for resolution. Continue to check Happening Now for updates.
Important Updates:
April 29, 2025: The TRICARE West Region Referral Waiver has been extended through June 30, 2025.
April 1, 2025: Behavioral health counselor claims were denied due to a supervisory requirement error. TriWest has corrected this issue and is working to reprocess the claims.
Providers should use the following TriWest resources:
To submit a corrected dental claim, simply send a Reconsideration with the changes needed or the requested EOB. If a new claim is submitted rather than a Reconsideration, it will automatically deny as duplicate since dental claims do not have XX7/XX8 claims like medical claims.
Do you have a new team member who would like to be added to our email list?
They can sign up for Provider updates online in the same location as our Provider Updates newsletter on the 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. Availity is a healthcare information technology platform providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association. TriWest manages health benefits for the United States armed forces and veteran communities and Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association, oversees provider network and credentialing for those health benefits in Nebraska.
