Medicare Advantage

Blue Cross and Blue Shield of Nebraska (BCBSNE), we deeply value the dedication and partnership of our providers throughout Western Nebraska. We are pleased to invite you to the BCBSNE Western Nebraska Provider Summit, taking place on Tuesday, July 15, 2025, in Kearney, Nebraska. 

This full-day event will offer valuable insights and updates on BCBSNE’s commercial and Medicare Advantage medical lines of business.

Summit highlights: 

• Comprehensive sessions on claims, reimbursement, and appeals  
• Medicare Advantage and policy updates 
• Education on Risk Adjustment, Quality Programs, and Value-Based Care (VBC)  
• Communication strategies and NebraskaBlue resources 
• Networking with peers and BCBSNE leadership 
• Interactive Q&A and collaborative discussions 

Event details:

Date: Tuesday, July 15, 2025
Check in: 8:30 A.M. (with breakfast and drinks)
Time: 9:00 A.M. – 3:30 P.M. (CT)
Location:
Holiday Inn Hotel & Convention Center
110 2nd Ave, Kearney, NE 68847 

Hotel accommodations: 

A group rate of $139.95 (plus taxes and fees) is available for the night of July 14 at the Holiday Inn in Kearney. To reserve, call (308) 237-5971 and mention “BCBSNE Summit” to receive the discounted rate. 

Meals provided: 

Breakfast, lunch, and beverages will be provided. Please ensure that each attendee registers individually to help us plan accurately for meals. 

Registration: 

BCBSNE Western Provider Summit - Kearney, NE: July 15, 9 a.m. - 3:30 p.m. 

Important deadlines:  

The deadline to register and secure the group hotel rate is June 13, 2025. Space is limited for both the summit and hotel accommodations—early registration is strongly encouraged. 

We look forward to seeing you in Kearney and showing our appreciation for the incredible work you do in Western Nebraska.

Beginning August 1, 2025, BCBSNE MA claims for readmissions will follow the CMS guidelines denying the second readmission. A detailed MA procedure will be published by June 1, 2025.

Effective May 1, 2025, Blue Cross and Blue Shield of Nebraska (BCBSNE) will introduce a new Advanced Provider Inquiries form on NaviNet. This form is designed to streamline the submission process by collecting all necessary information upfront, enabling the appropriate support team to address the inquiry efficiently and reducing the number of communications required.

Provider Executive Support Areas:

• Escalated Claims Inquiries
• NaviNet System Issues
• Provider Education Opportunities
• Medicare Advantage Rate Letters
• Open Negotiation Requests

Important Changes:

• The new Advanced Provider Inquiries form does not replace the existing Claims Investigations process on NaviNet. Providers must continue to submit Claims Investigation requests before using the new form to contact the appropriate support team.
• As of May 1, 2025, the ProviderExecs@NebraskaBlue.com email account will be decommissioned. Providers will no longer be able to send requests to this email address.

Next Steps: For more information regarding the new process, please watch the Advanced Provider Inquiries eLearning module and monitor this page for updates as the effective date approaches.

Blue Cross and Blue Shield of Nebraska (BCBSNE) would like to remind providers of the following guidelines regarding MA prior authorizations (PA):

• Observation Level of Care: No prior authorization (PA) submission is required for Observation level of care.
• Inpatient Admissions: Prior authorization (PA) is required for inpatient admissions.
• Upgrading from Observation to Inpatient: If a patient is upgraded from Observation to an inpatient level of care, please submit a PA request via NaviNet. Ensure that the observation dates are included to bundle the observation days with the Diagnosis-Related Group (DRG) for claims and billing purposes.

We are pleased to announce that on July 15, we will be hosting a Western Nebraska Provider Summit in Kearney, Nebraska. This event is designed to provide valuable insights and updates on Blue Cross and Blue Shield of Nebraska's (BCBSNE) commercial and Medicare Advantage lines of business.

Our focus is on our provider partners west of Omaha, and we highly value your input to tailor the summit to meet your needs. Please take a moment to complete the survey below by May 1 to let us know your preferences and any specific topics you would like to see covered.

Input Survey

Please note that this event will focus exclusively on medical topics. However, we are planning to host a behavioral health and dental forum in late 2025 or early 2026.

We look forward to your participation and to making this forum a valuable experience for all attendees. Please keep an eye on the Happening Now in May for more information on the event and how to register.

Blue Cross and Blue Shield of Nebraska (BCBSNE) recently identified an issue with the processing of certain Medicare Advantage (MA) claims that have frequency limits, such as mammograms. Here are the key points:

• Issue Identified: When both facility and professional claims were submitted for services with frequency limits, only one of the two claims was allowed. The claim processed last was denied with the message: "This procedure exceeds the maximum frequency allowed per Medicare Advantage guidelines."
• Correction Implemented: The issue has been identified and corrected. All claims processed after March 25, 2025, are now being handled correctly.
• Reprocessing Affected Claims: BCBSNE is identifying and automatically reprocessing the affected claims that were processed incorrectly between January 1, 2025, and March 24, 2025.
• No Action Required: There is no need to resubmit these affected claims. Please allow 30-45 days for the reprocessing of these claims.

The authorization templates for MA Inpatient Acute Medical, Inpatient Acute Surgical, and Inpatient Observation have been consolidated into a new and improved MA Inpatient Acute Care template. This streamlined template enables providers to select from various treatment types, including Observation, Medical (inpatient), Surgical (inpatient), and Transplant (inpatient). 

In cases where an authorization is initially reviewed and approved with an Observation treatment type, and the provider wishes to submit an extension that transitions the patient from observation to an acute level of care, the provider should select one of the applicable non-observation treatment types at the additional extension line level.

Billing MA claims accurately is crucial for providers to ensure timely reimbursement and compliance with regulations. Currently, we are seeing MA claims with a 114 TOB being billed where the member was admitted in 2024 but the statement dates on the 114 TOB claim are all in 2025.

To address this issue, BCBSNE will soon introduce new edits to reject specific TOB/REV Code combinations or TOB/Status Code combinations. Here’s a guide to help providers navigate these changes and maintain consistency in billing practices.

Understanding TOB Codes

Type of Bill (TOB) codes are essential for indicating the nature of a claim. For Medicare billing, certain TOB codes are valid, while others are restricted. Here are the key points to remember:

• TOB 112: This code is valid for Medicare billing. Hospitals should use TOB 112 for initial interim claims, indicating that a patient is expected to remain in the facility for an extended period.
• TOB 117: After the initial interim claim has been submitted, TOB 117 should be used for continuing and final claims. This ensures that the billing reflects the ongoing care and eventual discharge of the patient.

Avoiding Invalid TOB Codes

Certain TOB codes are not valid for Medicare PPS claims. Providers should be aware of the following restrictions:

• TOB codes 0XX3 and 0XX4: These codes are not valid on Medicare PPS claims. Providers must resubmit claims with the appropriate TOB 0XX7.
• Interim continuing and final claims: Instead of using TOB 0113 or 0114, providers should submit claims using TOB 0117. This involves submitting an adjustment to cancel the original interim bill and rebilling the stay from the admission date through the discharge date.

Consistency in Billing Rules

By following the guidelines outlined above, providers can ensure their claims are processed correctly and avoid rejections due to invalid TOB codes.

Conclusion

Adhering to the proper billing practices for Medicare claims is essential for providers to maintain compliance and ensure accurate reimbursement. By understanding and applying the correct TOB codes, providers can navigate the edits and continue to deliver quality care without disruptions in billing.

For any further questions or clarifications, providers should reach out to their billing support team or consult the latest Medicare billing guidelines.

Our Medicare pricing tool utilizes the NPPES data registry to link the Medicare Number/CCN with the NPI data listed in the registry. If there is a discrepancy between the data in the registry and what is submitted on the claim, the claims may be delayed or potentially returned. Therefore, it is crucial for providers to ensure accurate updates to the NPPES and to deactivate outdated information.