BCBSNE’s Medicare Advantage plan is moving in-house for 2025
We’re excited to announce that in 2025, we will bring the operations of our Medicare Advantage (MA) program fully in-house, providing key benefits for you, our health care provider partners.
What’s changing?
Currently, Blue Cross and Blue Shield of Nebraska (BCBSNE) works with a third-party vendor to manage our MA program. Effective Jan. 1, 2025, we will bring the operations of our MA program fully in-house. This change will enable us to better support you, our health care provider partners, in serving your patients who have a BCBSNE MA plan. Key benefits will include:
Utilization Management:
Providers will be able to submit MA preauthorizations via NaviNet®. These preauthorizations can be tracked in the same way as our commercial members' preauthorizations.
The types of preauthorizations that may be submitted via NaviNet will be expanded for MA plans.
Discharge planning will be managed directly by BCBSNE.
Claims processing:
BCBSNE will process MA claims directly. You can expect the claims process for MA to mirror BCBSNE’s familiar commercial claims process. This will allow BCBSNE to provide you with an enhanced experience, as our Provider Executive team will have increased visibility into claims and be able to support you should you have questions.
Enhanced customer service experience:
BCBSNE will have a Nebraska-based customer service team available to answer MA questions once the transition is complete. Please note: The customer service phone number for MA will not change. Please continue to call 888-505-2022 for BCBSNE MA member eligibility, benefits and claims questions.
Access to Medicare Advantage on NaviNet:
After the transition is completed on Jan. 1, 2025, providers will have access to claims, eligibility, benefits, preauthorization and other items available on NaviNet for the Medicare Advantage line of business.
We will share more information about this change soon. If you have any questions in the meantime, please reach out to your Provider Executive.
Medicare Advantage Claims Update
When submitting Medicare Advantage claims, CMS standards must be followed to prevent unnecessary returns and processing delays. Effective June 4, 2024, with the CMS edits in place you will see non-Nebraska MA claims process more appropriately. Below are three common CMS standards that would need to be followed to avoid claims being returned or denied.
DME NU & RR Modifiers
Claims that are billing supply codes with NU modifier, and they do not require an NU modifier, will be denied.
If billed without BP and BR modifiers that go with certain rentals, they will be denied as well.
Federally Qualified Health Centers (FQHC) and Rural Health Claims
Per CMS guidelines, Medicare Advantage FQHC and Rural health claims will need to be billed on a UB04 instead of on a CMS 1500 form.
We were not enforcing before and are now and will be returning or denying claims as appropriate.
Ambulance for MA only
Per CMS guidelines, ground mileage totaling up to 100 covered miles must be reported to the nearest tenth of a mile. In addition, all air ambulance mileage must be reported as fractional units to the nearest tenth of a mile. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile.
Professional Electronic – When submitting fractional units, the Provider needs to submit the same fractional units in the Ambulance Mileage field on the 837P AND the units field.
Professional Paper (CMS-1500) – When submitting fractional units, the Provider needs to submit the fractional units in the units field.
Institutional Electronic – When submitting fractional units, the Provider needs to submit the fractional unit in the units field. There is not a separate Ambulance Mileage field on the 837I for Institutional.
Institutional Paper (UB-04) – Providers should continue to submit whole units as decimals are not allowed on the UB in the units field.
Claims will be returned if not submitted correctly.
Durable Medical Equipment Reimbursement Cap
Effective July 19, 2024, BCBSNE is no longer required to reimburse Medicare Supplement suppliers or beneficiaries for any durable medical equipment purchases greater than 115% of the Medicare-approved amount. Before receiving services, we encourage members to ask if their provider accepts Medicare or Medicare Assignment. If they do not, members may incur higher out-of-pocket costs.
For more information on this new State Mandate please refer to the Legislative Updates on our Provider Resources page.
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.
Department of Corrections Claims
The Department of Corrections has made a change to their member benefits that impacts the way claims are processed. Beginning Jan. 1, 2024, members whose ID numbers begin with 888 and are IP longer than 24 hours, could qualify for Medicaid.
If the member does qualify for Medicaid, the Department of Corrections will inform the provider of the Medicaid coverage. Claims submitted to BCBSNE for these members will deny as provider liability.
These claims will not be eligible for appeal or reconsideration. There is no need to contact Member Services or your Provider Executive. Please direct questions about these denials to the Department of Corrections or Medicaid for eligibility information if needed.
Department of Corrections Claims FAQs Q: Why does the Department of Corrections member still show as active in NaviNet when inpatient claims are to be sent to Medicaid if the member has qualified for Medicaid? A: As only inpatient hospital and inpatient professional claims should be sent to Medicaid when the Department of Corrections member has qualified for Medicaid, these members still have benefits for outpatient services through BCBSNE. Outpatient service claims for Department of Corrections members should be sent to BCBSNE.
Q: Does NaviNet provide detail on when inpatient claims for a Department of Corrections member should be sent to Medicaid? A: If a member's inpatient hospital and inpatient professional claims should be sent to Medicaid, NaviNet Eligibility and Benefits and category "Hospital - Inpatient" will show "Not Covered". Claims should be sent to Medicaid.
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 at 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.
