Happening Now
Please continue to watch Happening Now for commercial and FEP updates.
For Medicare Advantage updates please reference the Medicare Advantage page.
Top three claim return reasons
To help providers submit accurate claims and take advantage of auto-adjudication, BCBSNE continues to rank the top three reasons for claim returns:
As we posted to Happening Now on Oct. 21, effective Oct. 28th, the following changes were implemented:
- Only the numeric portion of the ID number needs to be entered for preauthorization requests. The alpha prefix is no longer required. However, claims must still be submitted using the full alpha-numeric ID number.
- Notes or an attachment of medical records must be added before launching InterQual®. You will not be required to submit both.
- For commercial business, when selecting criteria guidelines in InterQual please confirm you are not selecting the Medicare Advantage (MA) criteria.
Important: All BCBSNE MA members will receive new ID numbers starting Jan. 1, 2025. Please ensure you are using their new ID number for services to be received on or after Jan. 1, 2025.
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 last verified.
In Q3 2024, only 73% of participating providers completed the attestation. 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.
For PHO groups handling their own credentialing processes, please continue submitting a full roster every 90 days.
We made a small but important enhancement to the Claim Appeal statuses in NaviNet. Now when you submit an appeal the status will change to “In Review” once your appeal is received. Although we can’t provide interim statuses on NaviNet, this change ensures you know your request is being processed. Once BCBSNE responds, the status will update to “Closed."
Below is a screenshot showing the new status button on the NaviNet appeal page.
For more information and guidance, please view our eLearning videos.
When duplicate line items are submitted for a service/item with a Medically Unlikely Edit (MUE) limit, the line-item denial reasons will be provided for both the duplicate claim/service and for exceeding the MUE limit.
Blue Cross and Blue Shield of Nebraska (BCBSNE) is updating our Peer-to-Peer procedure GP-P-003 with the following changes:
Peer-to-peer reconsiderations of not medically necessary denials on prospective and concurrent reviews must now be scheduled within 48-hours of the denial, reduced from the previous 14 calendar days. If a peer-to-peer request is not scheduled within this 48-hour window, the provider will need to submit an appeal request.
Emails are handled in the order received; however, emails are not worked unless the below information is included.
- Provider name, NPI and TIN
- Claim numbers (if applicable)
- Member name and ID
- DOS
- Expected outcome or reimbursement
Additionally, the appropriate steps MUST be followed first BEFORE submitting an escalation request to this email box.
Step One: NaviNet®
Please access NaviNet for all member, claim, authorization and appeal needs. If you do not have access to NaviNet please register by following the steps under Provider Academy.
Step Two: Contact
If NaviNet is unsuccessful, please use the claims investigation tool located in NaviNet.
Step Three: Escalating
For claim escalation needs that you are unable to resolve through NaviNet or Customer Service Claims Investigation, you can email this email box and include why NaviNet or Claims Investigation was not successful including the inquiry number from Customer Service.
FOR FEE SCHEDULES:
All fee schedules are available in NaviNet and will NO LONGER be available via CSC, email or inquiry.
If you are affiliated with a PHO, you must obtain the fee schedule from the PHO.
FOR TIMELY FILING:
Please submit your request via NaviNet using the Timely Filing form.
Please remember – COB is not a member ID exception please complete the reconsideration form on NaviNet if another insurance was billed, recouped or denied the claim and you then submitted to BCBSNE.
Provider Executives no longer address COBs submitted incorrectly on a timely filing form.
The Nebraska Applied Behavior Analyst (ABA) Board has announced that all Behavior Analysts practicing in Nebraska must obtain state licensure within 90 days following Sept. 2, 2024.
BCBSNE will update licensure requirements for this provider type during recredentialing. For those applying for initial credentialing, previous board certification will still be required.
The Nebraska Applied Behavior Analyst (ABA) Board has announced that all Behavior Analysts practicing in Nebraska must obtain state licensure within 90 days following Sept. 2, 2024.
BCBSNE will update licensure requirements for this provider type during recredentialing. For those applying for initial credentialing, previous board certification will still be required.
We are pleased to announce a significant partnership between TriWest, an affiliate of the BCBS Association, and Blue Cross Blue Shield of Nebraska (BCBSNE). TriWest has been awarded the Western Region TRICARE contract to be effective 1/1/2025. Health Net will no longer be the fiduciary. Thus, to continue participation with TRICARE, providers will need to sign with TriWest.
TriWest is actively expanding its network in Nebraska via BCBSNE and is distributing documents to providers through DocuSign. For those already part of NEtwork Blue, BCBSNE's credentialing process will suffice, meaning there are no additional credentialing steps. We urge you to promptly review and sign the contract sent to you, which includes a DocuSign link sent from dse_NA4@docusign.net; it's possible this email was directed to your spam folder. If a new contract is needed or if you haven't received yours, please contact us without delay at BCBSNEProviderContracting@NebraskaBlue.com for resolution. Furthermore, if you decide not to join the network, please inform us so we can keep our records current.
For any inquiries or assistance, please feel free to contact us.
Frequently Asked Questions (FAQ) - TRICARE
Q: I’m already contracted with TRICARE; do I need to take any action?
A: Yes, all contracts with TRICARE’s previous administrator Health Net will expire at the end of 2024. To be considered In-Network for TRICARE in 2025, you will need to sign an agreement with TriWest.
Q: Is Blue Cross and Blue Shield of Nebraska (BCBSNE) collaborating with TriWest?
A: Yes, TriWest, which is an affiliate of the BCBS Association, has been awarded the Western Region TRICARE contract to be effective 1/1/2025. BCBSNE and TriWest are in partnership to establish a comprehensive network for TRICARE beneficiaries. BCBSNE oversees the management of the provider network and the credentialing process for healthcare providers within Nebraska.
Q: How can I access the fee schedule related to my TRICARE agreement?
A: The fee schedule is available on the official Military Health System website. You can view the rates and reimbursement details for TRICARE by visiting the TRICARE Allowable Charges page under the Rates and Reimbursement section. (TRICARE Allowable Charges | Health.mil)
Q: In case of any issues with my TRICARE contract, whom should I contact?
A: For any contract-related inquiries or issues, please reach out via email to BCBSNEProviderContracting@NebraskaBlue.com.
Answers from AAHAM:
- Not all TriCare plans have OON benefits, it is important to check benefits
- TriCare refers to contracted providers
- Prior auths will be honored for contracted providers
- Providers will not need to be recredentialed as long as TriCare credentialing requirements are met
Effective July 19, 2024, BCBSNE is not 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.
Effective May 1, 2024, BCBSNE will not extend agreements to credentialed providers with out-of-state tax IDs. Providers with locations in both Nebraska and a contiguous county state using the same tax ID will be permitted to add a location outside the state of Nebraska.
Providers who have delegated credentialing are not impacted by this rule.