Transition to electronic remittance advices and payments
Blue Cross and Blue Shield of Nebraska (BCBSNE) continues to further our paperless transition with a shift toward electronic remittance advices and payments.
Effective Oct. 1, 2025, paper remittance advices will be discontinued. Providers can receive 835s by signing up with a clearinghouse or accessing remittance advices in NaviNet.
Effective Oct. 1, 2025, the option to receive paper checks will be discontinued. Providers currently receiving paper checks will need to fill out an electronic funds transfer (EFT) form to receive electronic payments.
Forms available on NaviNet®: The necessary forms for signing up for EFT and enrolling in the electronic remittance advice service are available under the Administrative Updates/Secure Forms link on NaviNet. Please complete these steps in advance of Oct. 1, 2025.
Exception for dentists: Due to limited self-service options in NaviNet, dentists can continue receiving paper remittance advices if they cannot enroll with a clearinghouse.
Paper remittance advices and paper checks will no longer be an option for newly credentialed providers effective July 1, 2025.
BCBSNE partnered 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.
In May 2025, Cotiviti began conducting periodic post-payment reviews of paid medical claims, including Clinical Claim Validation (CCV). This collaboration enhances 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 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.
BCBSNE partners with Conduent to enhance payment accuracy for ED claims
At BCBSNE, we are committed to ensuring appropriate reimbursement and supporting high-quality, cost-effective care. As part of this effort, we’re partnering with Conduent, a trusted leader in health care operations, to conduct coding reviews of Emergency Department (ED) claims. While we understand that claim reviews may not always be welcome news, this partnership is intended to support consistency and accuracy in reimbursement.
Starting Sept. 1, 2025, Conduent will begin reviewing ED claims to determine the appropriate level of reimbursement based on the diagnosis and services billed. This initiative is designed to align with industry standards and promote accurate, fair payment for services rendered.
What providers can expect
The ED claim review process focuses on promoting billing accuracy and fairness.
If a claim is selected for review, you will receive a letter identifying notifying you of the overpaid claim(s) along with a detailed explanation of why the claim is overpaid. The review process will follow our standard contractual lookback period, typically 12 months. Reviews will include all lines of business.
You may choose to appeal, following the steps in the letter. Medical records may be requested if they have not already been submitted to BCBSNE. We are working closely with Conduent to minimize these requests and streamline the process for providers.
About Conduent
Conduent is a Business Associate of BCBSNE, as defined under HIPAA (45 CFR §160.103), and will perform its responsibilities in full compliance with HIPAA requirements. With deep expertise in health care operations, Conduent supports payers and providers in improving outcomes, reducing costs and enhancing operational efficiency.
Your partnership matters
We appreciate your cooperation in providing Conduent with the necessary medical and/or financial information to complete these reviews. Requests will follow the same methods previously used by BCBSNE, including mail, fax and EMR access.
Thank you for your continued partnership and commitment to delivering quality care to our members. Please share this information with your teams as appropriate.
How to submit a claim
The preferred way to submit claims is through the Electronic Data Interchange (EDI). Claims can be submitted through your preferred clearinghouse as long as you are a BCBSNE-credentialed provider. If you do not already have a clearinghouse, BCBSNE offers free billing software and support to help you submit claims electronically. Learn more about the Electronic Data Interchange and PC-ACE Software.
If circumstances necessitate submitting claims on paper temporarily, please inform your Provider Advocate. Their information can be found on NebraskaBlue.com/ProviderContacts.
This notification will enable us to prepare for the receipt of paper claims and help mitigate any potential downstream delays.
For BCBSNE Medicare Advantage (MA) members with the YMA4 or Y2M4 prefix, timely filing denial appeals must be submitted using the Appeal option in NaviNet®. Please be advised that paper submissions will not be reviewed.
This process is the same as the one currently used for commercial members.
Reminder: Viewing 2024 MA claims in NaviNet
Providers can now view 2024 MA claims through the Claim Status tool in NaviNet.
To access claim details, please use the member’s 2024 ID number, which includes one of the following four-letter prefixes:
YMAN
Y2MN
Using the correct member ID ensures accurate claim lookup and helps streamline your workflow.
Expansion of prior authorization (PA) requirement for specialty drugs
In our June Provider Bulletin and on Happening Now, we previously announced that the management of certain specialty drugs under the medical benefit will be expanded to include our Commercial members. Beginning Sept. 30, 2025, providers should begin contacting Prime Therapeutics to obtain PA for the in-scope drugs for our Commercial members with dates of service on or after Sept. 30, 2025.
PA will be required for the medical specialty drugs for Commercial and Medicare members when they are administered in the following settings:
Physician office (POS 11)
Patient homes (POS 12)
Outpatient facilities (POS 19, 22)
For routine requests and clinical guideline information please visit GatewayPA.com.
For urgent and expedited requests please call 800-424-1709.
Benefits of the Virta® program for your primary care team
Managing type 2 diabetes can be challenging for both patients and their primary care teams. The Virta program offers a comprehensive approach that supports your team in delivering effective diabetes care. Here are the key benefits for your practice when your patients enroll in the Virta program:
Addresses underlying causes
Virta uses a highly individualized approach to carbohydrate intake and nutritional ketosis, accounting for each patient’s unique biochemistry, medications and lifestyle. This personalized method helps address the root causes of diabetes, leading to better patient outcomes.
Physician-led remote diabetes care
Your patients benefit from continuous, technology-enabled remote care provided by Virta’s physician-led team. This approach allows for the safe reduction and elimination of diabetes medications, ensuring your patients receive expert care without the need for frequent in-person visits.
Sustainable behavior change
A dedicated health coach provides personalized guidance and accountability, helping your patients create long-term behavior changes that lead to sustainable results. This support can significantly improve patient adherence to treatment plans and overall health.
Supplements primary care
Virta coordinates with your primary care team to keep you up to date on your patients' progress and changes to their treatment plans. This collaboration ensures that you are informed and can adjust your care strategies accordingly.
Amazing, published outcomes
In as little as 10 weeks, individuals with type 2 diabetes can improve glycemic control, decrease medication use, and achieve clinically relevant weight loss. Published results include: 5% diabetes reversal; 1.1% average HbA1c reduction; 20% average reduction in triglycerides and 91% patient retention
Clinical success
The Virta program helps your patients meet clinical goals for diabetes management, including improvements in A1c levels and weight. This success translates to better health outcomes and reduced complications for your patients.
Save time
Your practice can save time by leveraging Virta’s daily nutrition and behavior counseling, as well as diabetes medication management. This allows your team to focus on other aspects of patient care and reduces the burden of managing diabetes.
Patient cost coverage
BCBSNE and self-funded employer groups cover the cost of Virta for members with type 2 diabetes, making it accessible to a wider range of your patients.
Exclusion criteria
The Virta program is not suitable for individuals younger than 18 years old, those aged 80 or older, type 1 diabetics, pregnant or nursing individuals, those with diabetic ketoacidosis in the past 12 months or those with stage four or five chronic kidney disease or end-stage renal disease on dialysis.
Why Virta works
Virta is an online specialty medical clinic that helps members reverse type 2 diabetes safely and sustainably, without the risks, costs or side effects of medications or surgery. By enrolling your patients in the Virta program, your primary care team can enhance diabetes care strategies and achieve better patient outcomes.
Note: Not all BCBSNE members have access to this offering. It is important for providers to refer to their patients' specific benefits plans to determine eligibility and coverage.
Value-Based Care
What is value-based care?
Value-based care (VBC) is a care delivery model that emphasizes quality and efficiency, with the goal of better health outcomes and experiences for members and providers. BCBSNE partners locally with primary care physicians to help coordinate care, keep quality high and lower the growth of health care costs.
What are the key principles of value-based care?
Patient-centered: Care is designed around an individual’s needs, goals and preferences.
Quality over quantity: Providers are rewarded for improving patient health outcomes, not for the number of tests or procedures performed.
Coordinated care: Emphasizes collaboration among providers to ensure seamless, holistic care.
Cost efficiency: Encourages the reduction of unnecessary services and promotes preventive care to lower overall health care costs.
Accountability: Providers are held responsible for both the cost and quality of care delivered to their attributed patient population.*
*Dependent upon the type of agreement between BCBSNE and the contracting entity.
What value-based care agreements are available at BCBSNE?
BCBSNE offers VBC agreements to:
Accountable care organizations (ACO):
Three-year term
Shared saving/risk models
Patient-centered medical homes (PCMH):
One-year term
Pay-for-quality model
Independent clinics:
One-year term
MA population
Pay-for-quality model
Eligibility criteria exist in each agreement offering and must be met to be eligible for participation.
Are all providers eligible to participate in BCBSNE’s value-based care agreements?
Currently, the following provider specialties are eligible to receive attribution in BCBSNE’s base value-based care agreements:
Advanced Registered Nurse Practitioner*
Family Practice
General Practice
Geriatric Medicine**
Gynecology
Internal Medicine
Nurse Practitioner*
Obstetrics-Gynecology
Pediatrics
Physician Assistant*
Preventive Medicine
*These providers can only be considered as eligible primary care physicians if practicing under one of the other provider specialties listed.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
NaviNet® NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska.
Cotiviti is an independent company providing post pay claims data mining and DRG audit services for Blue Cross and Blue Shield of Nebraska.
Conduent is a business process outsourcing company providing healthcare administrative services for Blue Cross and Blue Shield of Nebraska.
Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and mail service company.
Virta is an independent company that provides diabetes management services to Blue Cross and Blue Shield of Nebraska.
Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross Blue Shield Association. The Blue Cross Blue Shield Association licenses Blue Cross and Blue Shield of Nebraska to offer certain products and services under the Blue Cross® and Blue Shield® brand names within the state of Nebraska.
