Happening Now

Blue Cross and Blue Shield of Nebraska (BCBSNE) transitioned its employee health plan telehealth provider to Telescope Health on April 1, 2025. Additional groups—including Behlen Manufacturing Co., MUD and NACO—joined on July 1, 2025. All other groups will transition Jan. 1, 2026.

When your patients use Telescope Health, your practice benefits from:

• Shared visit notes for better care coordination
• Referrals to local in-network providers
• Access to primary care providers 24/7
• Convenient hours with behavioral health providers 

Check patient benefit plans for eligibility, as not all members have access.

For full details, see the August issue of the Provider Bulletin.

^{Telescope Health is an independent company providing telehealth services for BCBSNE, an independent licensee of the Blue Cross Blue Shield Association.}

Effective Aug. 1, 2025, medical policy III.219, concerning biventricular pacemaker with and without ICD will undergo significant change. Procedure code 33249 will now require preauthorization regardless of whether the ICD is dual or single chamber.

This policy update aims to ensure that all patients receive appropriate and necessary care while maintaining the integrity of the healthcare system. Providers are encouraged to familiarize themselves with the preauthorization requirements to avoid any disruptions in patient care.

For further information and detailed guidelines, please refer to the updated medical policy.

We want to let you know about an upcoming change to our weekly batch claim payment schedule that will go into effect Nov. 1, 2025. We wanted to give you advance notice so you can analyze and prepare for the short-term impact this change will likely have on your organization.

Starting Nov. 1, each weekly batch claims payment will be comprised only of claims with receipt dates of at least 21 days. We are also shifting the weekly payment settlement date from Thursdays to Mondays. This change applies to all Blue Cross and Blue Shield of Nebraska (BCBSNE) lines of business, excluding the Federal Employee Program (FEP).  

We are making this change to reduce the need for post-payment corrections, which causes an administrative burden for providers and confusion for patients. In addition, we are subject to audits and validations to demonstrate accuracy for much of our government business, including Medicare Advantage and ACA plans.  Making this change ensures we have sufficient time to review and validate claims prior to payment.

This new payment cadence supports our ability to continue to provide you with timely payment in alignment with industry standards. Other carriers’ payment cycles range from 21-45 days.

Illustration of difference between current and new payment schedules

Short-term impact of payment cycle change

Because only claims with receipt dates of 21 days or more will be included in each weekly batch, it should be anticipated that for the first three weeks of the new schedule, your organization’s reimbursement amount will be lower than previous weeks, until the new cycle aligns with the adjusted cadence.

Improving the efficiency of our payments to you, as well as making interactions with the health care system less complicated and confusing for our members, are among our top priorities. If you have any questions about this upcoming change, please email Provider Partnership Director Dana Medeiros at Dana.Medeiros@NebraskaBlue.com with the subject line, Payment Schedule Change.

Virta is a provider-led, research-backed program that helps patients reverse prediabetes and type 2 diabetes through personalized nutrition, remote care and behavior change support. Patients can lower A1C, reduce or eliminate medications, and lose weight — without surgery.

How You Can Help
Encourage patients to verify their benefits. Many BCBSNE and self-funded plans cover the full cost.

Why Recommend Virta?

• Treats root causes, not just symptoms
• Offers physician-led remote care
• Supports lasting lifestyle changes
• Coordinates with your care team
• Saves time and improves outcomes

Getting Started Is Easy
Patients answer a few questions, and Virta follows up with next steps.

Note: Not all BCBSNE members are eligible. Always verify coverage.

Learn more at NebraskaBlue.com/Diabetes.

As part of BCBSNE’s continued efforts to streamline operations and reduce paper usage, we are reminding all providers that the transition to electronic remittance advices and payments is rapidly approaching. The deadline is Oct. 1, 2025 — action is required now to avoid disruptions.

• Paper remittance advices will be discontinued effective Oct. 1, 2025. Providers must begin receiving 835s through a clearinghouse or by accessing remittance advices in NaviNet.
• Paper checks will no longer be an option after Oct. 1, 2025. Providers currently receiving paper checks must complete the electronic funds transfer (EFT) form to continue receiving payments.
• Forms are available on NaviNet. Visit the Administrative Updates/Secure Forms section to access the necessary forms for EFT and electronic remittance advice enrollment. Please complete these steps as soon as possible.
• Dentist exception: Dentists who are unable to enroll with a clearinghouse may continue receiving paper remittance advices due to limited self-service options in NaviNet.

Time is running out: Providers who do not complete the transition by the deadline may experience delays in payment and remittance delivery.

We’ve made it easier to submit appeals, timely filing requests, and reconsiderations through NaviNet^®. As of June 26, 2025, you’ll now select a reason instead of a “type,” simplifying the process and improving efficiency.

Why submit through NaviNet?

• Instant confirmation: Know your request was received the moment you submit it—no waiting, no wondering.
• Real-time visibility: Track the status of your submission directly in NaviNet. No need to call or fax for updates.
• Faster routing: Your request is automatically directed to the correct department, reducing delays and rework.
• Streamlined Process: A new update lets you select a reason for your request instead of a “type,” making submissions faster and more intuitive.
• Paper-Free Convenience: Eliminate printing, faxing, and mailing—submit everything digitally, including supporting documents in PDF format.
• Built-In Security: NaviNet lets you securely send appeals and medical records using HIPAA-compliant tools.

How to submit:

1. Go to your claim status details
2. Click Appeal and choose a reason
3. Add notes, attach PDFs, and submit

Make the switch today—NaviNet is faster, easier, and more efficient.

When submitting an Advanced Provider Inquiry, the NaviNet NPS number is not considered a valid CSC reference number.

If a request requires a reference number for submission, it must include a valid number from a phone call or a Claims Investigation. Requests submitted without a valid reference number will be returned without review.

For more information, please watch the Advanced Provider Inquiries eLearning module. 

Thank you for your attention to this process.

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.

**Specific to Medicare Advantage Attribution

For further inquiries regarding our VBC opportunities, please contact VBPQuestions@NebraskaBlue.com.

Effective Aug. 1, 2025, the high dollar claim threshold will be adjusted from the current $100,000.

As part of our continued efforts to improve claims processing and oversight, we are updating the threshold that triggers our high dollar claim review process.

What’s Changing?

•  Commercial & Other Lines of Business:
  • New Threshold: Claims equal to or exceeding $75,000 will be subject to high dollar review.
  • Previous Threshold: $100,000
• Medicare Advantage (MA) Claims:
  • New Threshold: Claims equal to or exceeding $50,000 will be subject to high dollar review.
• Effective Date: Applies to any discharges on or after Aug. 1, 2025.

What You Need to Do:

•  Ensure your billing and administrative teams are aware of the updated thresholds.
• No action is required for claims below the applicable thresholds or for discharges prior to Aug. 1, 2025.

We appreciate your attention to this update and your continued partnership. 

At Blue Cross and Blue Shield of Nebraska (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.

As of June 26, 2025, we have streamlined our process for submitting appeals, timely filing requests, and reconsiderations via NaviNet. The previous system, which required selecting a “type” (Appeal, Recon, or Timely Filing), was replaced with a “reason” dropdown menu.

New submission process

Step 1: Go to your claim status details.

Step 2: Click on the Appeal button and select the reason for your request.

Step 3: Add free-form text, attach any supporting documentation (in PDF format), and submit the request.

These changes aimed to simplify the submission process and improve efficiency. Stay tuned for more updates and ensure you are familiar with the new system to make the transition smooth.

Visit our Provider Academy to view the eLearning videos to learn more.

We recently communicated a change in the management of certain specialty drugs under the medical benefit for Medicare Advantage (MA) members. This program is expanding to include our Commercial members. Beginning Sept. 30, 2025, providers should begin contacting Prime to obtain prior authorizations for the in-scope drugs for our Commercial members with dates of service on or after Sept. 30, 2025. 

Prior authorization 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 request and clinical guideline information please visit GatewayPA.com.

For urgent and expedited request please call 800-424-1709

We appreciate your support to ensure that our members continue receiving high-quality and clinically appropriate care. If you have questions, please contact your Provider Partnerships Advocate.