Mandated Changes Coming to Provider Directory Updates
The Consolidated Appropriations Act (CAA), effective Jan. 1, 2022, requires that online provider directory information be reviewed and updated, if needed, at least every 90 days.
We ask that you take a few minutes to review your online provider directory information to help ensure Blue Cross and Blue Shield of Nebraska (BCBSNE) members can locate your most current information.
If changes are needed, please take the time to update your information by submitting updates and corrections via one of our provider forms on NebraskaBlue.com/Providers/Find-a-Form.
COMING SOON: Beginning Oct. 1, 2022, all providers, including dentists, can begin to review directory information using NaviNet. For PHO groups handling their own credentialing processes, we will be requesting submission of a full roster every 90 days.
Coming this Fall: New Policies and Procedures Tool
We are happy to announce that coming this fall, policies and procedures will be available via a searchable database!
This new tool will include policies from these manuals:
General Policies and Procedures Manual
Billing and Reimbursements Manual
Dental Policies and Procedures
NOTE: Medicare Advantage policies will not be available in this tool. The Medicare Advantage Policies Manual will continue to be available on the Policies and Procedures page.
Here is a preview of what the tool will look like:
Nebraska HeartlandBlue
We are excited to announce that we will be entering the ACA market with our new Nebraska HeartlandBlue plans, allowing us to offer more coverage options to Nebraskans. These plans, offered in all 93 Nebraska counties, will utilize our existing networks; however, there will be no coverage for services received outside the state of Nebraska with the exception of emergency services. Because of this difference, you will see “HB” behind each of the networks offered with Nebraska HeartlandBlue.
NEtwork BLUE HB
Blueprint Health HB
Premier Select BlueChoice HB
These plans can also be identified by their alpha prefix YST or YNQ.
Nebraska HeartlandBlue plans will be sold during the upcoming Open Enrollment Period beginning Nov. 1, 2022, for a Jan. 1, 2023, effective date.
More NaviNet Changes Coming Soon!
To continue to make it easier to work with us, new self-service features are coming to our provider portal, NaviNet. Our second release will include the ability to view a copy of the member’s ID card, access additional benefits and view status for claims not available in NaviNet today. More communication will be coming soon on the release of these enhancements. If you are not already using NaviNet, make it a priority to register today at Connect.NaviNet.net/Enroll.
MEDICARE ADVANTAGE
Medicare Advantage Newsletter
Beginning with this issue of the Update, Medicare Advantage will no longer have a separate newsletter. All Medicare Advantage articles will be published in the Update.
Prior Medicare Advantage newsletters will still be available on the Alerts and Updates page.
Free Medicare Seminars
The Medicare Annual Enrollment Period (AEP) starts Oct. 15, 2022, and runs through Dec. 7, 2022. Many of your patients may be reviewing their current Medicare plan or are shopping for a new one. BCBSNE is offering free informational seminars at various locations and virtually to help patients understand the basics of Medicare and learn about what plan may fit their needs. Original Medicare, Medicare Advantage, Medicare Supplement plans and Part D prescription drug plans will be discussed. If your patients are asking about Medicare coverage or the AEP, please encourage them to attend one of our seminars. Patients may find a seminar near them, and should reserve a seat, by visiting Medicare.NebraskaBlue.com/Seminars.
PROVIDER EDUCATION
Diabetes Solutions: Virta
Beginning Jan. 1, 2022, BCBSNE members may use the Virta type 2 diabetes reversal program at no cost. Virta is a provider-led, research-backed treatment program that can help reverse type 2 diabetes. Patients can lower their blood sugar and HbA1c, all while reducing the need for diabetes medications and losing weight.
Virta’s proven results include:
1.0% reduction in HbA1c
5% weight loss
40% cost reduction in diabetes medications
How Virta works
Virta uses nutritional ketosis to naturally lower blood sugar and turn the body into a fat-burning machine. There is NO surgery, required exercise or calorie counting with Virta.
With Virta’s personalized treatment plan, each patient gets medical supervision from a physician-led care team, a one-on-one health coach, diabetes testing supplies, educational tools like videos and recipes and a private online support community.
Virta provides around-the-clock monitoring and care—there are no waiting rooms and no lines. With an easy-to-use mobile and desktop app, Virta can be done from anywhere.
If an OTC drug is billed under a prescription drug HCPCS code such as J3490, the claim will be denied/returned for an invalid NDC number.
Currently, OTC drugs should be billed under A9150. When filing electronically, the NDC number must be submitted in loop 2410 and in the following format: xxxxx-xxxx-xx.
Modifier 52: When to Use – How it Pays
Modifier 52 is considered a payment modifier, meaning payment is reduced when this modifier is applied. BCBSNE has recently reviewed our payment policy for modifier 52 and decided to apply a 50% reduction in payment to procedures with modifier 52 attached. It was determined this change more accurately reflects the reduction in services based on average provider work and practice expense involved. This change is scheduled to take place in the fourth quarter of 2022.
Metabolic Syndrome: Coding and Documenting
In category E70-E88 of the ICD-10 codebook, there are numerous metabolic diseases that risk adjust. It is very important in this category of ICD-10 codes to be as specific as possible when choosing the correct diagnosis code as well as documenting the condition of a member with a metabolic disorder or metabolic syndrome.
Metabolic conditions have a wide range of treatments; some are hereditary/genetic or currently without a cure. This means that a person could require lifelong medications or need to make lifestyle changes to manage their symptoms.
Metabolic syndrome, also called insulin-resistance syndrome, is a group of conditions that together increase the risk of coronary heart disease, diabetes and stroke amongst other serious health problems. Thus, it is very important for members to be monitored and health care providers should review specialty notes from previous encounters to ensure the member keeps and follows through on appointments, treatments, dietary restrictions, exercise programs and medications.
Many times, metabolic conditions are grouped into an unspecified category such as E88.9 when the condition of the member could or should be more defined. It is always best practice to have a coding team periodically review unspecified diagnosis and query health care providers to see if a member’s condition may fit into a more specific ICD-10 code.
Metabolic conditions and complications should always be documented in the assessment portion of the progress note and the most specific diagnosis code with highest level of specificity should be captured on claims to be reported for risk adjustment.
Blood Pressure Coding can Reduce HEDIS® Medical Record Requests
The Controlling High Blood Pressure (CBP) HEDIS® star measure assesses patients 18-85 years of age who had a diagnosis of hypertension reported on an outpatient claim and whose blood pressure was adequately controlled (<140/90 mm Hg) as of Dec. 31 of the measurement year.
Per HEDIS specifications, blood pressure CPT® II codes can now establish patient compliance with the CBP measure. We will no longer need to review medical records to confirm blood pressure values when you add the CPT II codes to your patients’ claims billed with an office visit, including telehealth, telephone, e-visit or virtual visit.
Blood pressure readings can be captured during a telehealth, telephone, e-visit or virtual visit. Please note:
Patient-reported readings taken with a digital device are acceptable and should be documented in the medical record.
Providers do not need to see the reading on the digital device; the patient can verbally report the digital reading.
Read the tip sheet to learn more about the measure and view a chart with blood pressure CPT II codes.
Health care Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CPT® is a registered trademark of the American Medical Association.
One in eight women in the United States will be diagnosed with invasive breast cancer in their lifetime, making it the second most common cancer in women, according to the American Cancer Society. Early detection is key to a better outcome for your patients, and you play an integral role by recommending regular screenings.
The Breast Cancer Screening (BCS) HEDIS® star measure assesses female patients ages 50-74 who had a mammogram to screen for breast cancer in the past two years.
The National Committee for Quality Assurance (NCQA) now allows patients to be excluded from the measure due to advanced illness and frailty. They acknowledge that measured services most likely would not benefit patients who are in declining health.
Read the tip sheet to learn more about this measure, including information to include in medical records, codes to include on patient claims to exclude for mastectomy and tips for talking with patients.
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
One of the best ways to make security part of your practice’s culture is to build it into your day-to-day operations. The first step in doing that is to identify:
Identify all equipment and software that your practice uses.
Identify security responsibilities for employees and business partners – discuss those responsibilities with them and define expectations.
Identify risks and ways to monitor for continual security.
As a contracting Blue Cross and Blue Shield of Nebraska health care provider, this newsletter serves as an amendment to your agreement and affects your contractual relationship with us. You are encouraged to file every issue of Update within your BCBSNE Policies and Procedures Manual and reference it often.
NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield of Association.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
