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:
Please ensure you are submitting TIN/NPI of providers who are credentialed with BCBSNE. Most importantly, do not submit claims for newly-credentialed providers until you have the acceptance letter with the provider’s effective date.
For credentialing guidance, please visit NebraskaBlue.com/Credentialing or the Administrative Updates/Secure Forms link on the BCBSNE NaviNet landing page.
If the TIN or NPI have changed, refer to the Changes of address, telephone number and/or tax identification number, or adding practice locations policy.
Please be sure to add the appropriate modifiers as this additional information helps to make sure your claim gets paid correctly for the services rendered.
Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code. They are used to add information or change the description of service to improve accuracy or specificity. Keep in mind that the use of modifiers should always follow the guidelines set by the American Medical Association (AMA) and other relevant coding authorities.
Important Information and Updates
Identity theft is a growing concern in healthcare, where sensitive personal and medical information is handled daily. Implementing robust identity theft precautions is crucial to safeguard patient information and maintain trust. One effective practice is verifying photo IDs, which plays a significant role in preventing identity theft and ensuring accurate patient identification.
Benefits of Photo ID Verification
- Accurate Patient Identification: Ensures the person receiving care is the patient on record, reducing medical errors.
- Enhanced Security: Adds an extra layer of security, making it harder for individuals to use stolen identities.
- Improved Trust and Confidence: Patients feel more secure knowing their information is protected, building trust in the provider-patient relationship.
By incorporating these measures into your daily operations, you can significantly reduce the risk of identity theft and enhance the overall patient experience.
TriWest is currently experiencing system issues, which may affect the availability of information for providers. This includes technical issues with the referral/authorization tool.
Providers should use the following resources:
- TRICARE West Region Referral Waiver Approval Letter
- Fax: 866-852-1893 (for same-day, urgent referrals, fax detailed information)
- Provider Services Email: providerservices@TriWest.com
- Provider Page: Welcome TRICARE West Providers
- Fee Schedule: CHAMPUS Maximum Allowable Charge Rates | Health.mil
- Reimbursement Manuals: TRICARE Manuals - Home
BCBSNE can assist with the following:
- Contracting Questions: bcbsneprovidercontracting@NebraskaBlue.com
- Adding Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page above
- Adding New group Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page above
- Adding Existing group Individual Providers to the TRICARE Roster: Submit changes through CAQH Provider Data Portal to have the provider’s information updated
Credentialing Variances for TRICARE Network in Nebraska:
- Licensure Disciplinary Actions: Providers with actions on their state licenses cannot be offered participation in the TRICARE network
- Board Certification: PAs, CRNAs, and CNMs must be board certified to be offered participation in the TRICARE network
Accreditation Requirements:
- Birthing Centers: Must be accredited by TJC, AAAJHC, CABC, or AABC and licensed according to state and local laws
- Substance Use Disorder Rehab: Must be accredited by TJC, CARF, or COA
- Intensive Outpatient Programs (IOP): Must be accredited by TJC, CARF, or COA
- Psychiatric Residential Treatment Facilities: Must be accredited by TJC, CARF, or COA
- Residential Treatment Centers (RTC): Must be accredited by TJC, CARF, or COA
Note: These requirements differ from our regular requirements, as we only verify accreditation but do not require it.
We kindly request that you share this information with your respective teams, as necessary.
Issue:
- The problem occurs when OOS providers submit authorizations through Availity to their local payer.
- The system fails to recognize the prefix, redirecting them to the Florida Blue Landing page.
- However, when they initiate the authorization process from the landing page, the system attempts to perform an eligibility check (which should be disabled) and requests a Provider Assigned Payer ID (PAPI), which OOS providers do not possess.
- This results in the process failing.
Cause:
- This issue is a result of UI changes implemented in Availity last year.
- We are actively collaborating with Availity to resolve this problem in production.
- A definitive date for a full fix is still being discussed and determined.
Next Steps:
- We are working closely with Availity to resolve this issue as soon as possible.
- In the meantime, OOS providers experiencing this issue should call the phone number on the back of the member's ID card to submit their authorization requests.
Effective Jan. 1, 2024, Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) can independently bill Medicare for services related to the diagnosis and treatment of mental illnesses. Medicare Part B will reimburse MFTs and MHCs at 75% of the rate paid to clinical psychologists under the Medicare Physician Fee Schedule.
Important Information for Providers:
- Medicare Opt-Out Status: If you have opted out of Medicare, please be aware that Blue Cross Blue Shield of Nebraska (BCBSNE) requires an affidavit from Medicare confirming your opt-out status with each claim submission. Without this affidavit, your claims will be denied for Medicare Explanation of Benefits (EOB).
- Opt-In Opportunity: We encourage MIDA providers to consider opting in to Medicare, as you now have the ability to do so. This change allows you to expand your services to Medicare beneficiaries and streamline your billing process
Please ensure that you are familiar with these updates and take the necessary steps to comply with the new requirements.
Marriage and Family Therapists & Mental Health Counselors
We are excited to share an important update regarding the verification of coverage for our members. With our recent enhancements, you can now accurately verify coverage using just the member’s name and date of birth. This means you no longer need the prefix and Card ID number to confirm active membership with our BCBSNE members.
We appreciate your attention to detail in ensuring our members receive the best service possible. Thank you for your continued dedication and support.
We are thrilled to announce a major win for our provider community! Effective Jan. 10, 2025, BCBSNE will no longer require preauthorization for the following codes related to continuous positive airway pressure (CPAP) devices:
- E0601
- E0561
- E0562
This change means more streamlined processes and less administrative burden for you, allowing you to focus more on patient care.
But that's not all! BCBSNE has also decided to reprocess claims received for dates of service beginning Jan. 10, 2025. Any claims previously denied will be automatically reprocessed, so there's no need for you to submit a reconsideration request. This is our way of showing our commitment to making your experience as smooth and hassle-free as possible.
Thank you for your continued partnership and dedication to providing excellent care. We are excited about this change and believe it will make a significant positive impact on your practice.
If the information on an already processed claim is incorrect or charges need to be added or voided, please submit a corrected claim electronically.
Steps to submit a corrected claim electronically
- Enter claim frequency type code: Place a value of 7 (replacement of prior claim) or 8 (void/cancel of prior claim) in Loop 2300 Segment CLM-Claim Information Field 05-3-Claim Frequency Type Code in the 837 file.
- Provide original claim number: Enter the original claim number assigned by Blue Cross and Blue Shield of Nebraska (BCBSNE) in Loop 2300 Segment REF*F8 - Payer Claim Control Number Field 02-Reference Identification.
- Corresponding elements on CMS claim form: These two element/segment values on the electronic claim form correspond to Box 22 on an 837P or Boxes 4 and 64 for an 837I (Claim Frequency Type Code and Claim Original Reference Number/Document Control Number) on the CMS claim form.
- Type of bill (TOB) 7: Indicates you are replacing a previously submitted claim. Do not change or remove data that needs to process again – submit the complete claim with the changes made.
Voiding and resubmitting claims
- Voiding incorrect claims: Claims submitted and processed under an incorrect patient and/or member identification (ID) number will need to be voided before a new claim is submitted. Resubmit the claim as it was originally submitted, but with a claim frequency code 8 to void the inaccurate claim record.
- Submitting a new claim: Submit a new claim with correct patient and/or ID information using claim frequency code 1. Claims with frequency code 1 do not need a claim number submitted in the original reference number field.
Submitting corrected claims with attachments
If you are not able to file your corrected claim electronically because your claim will include attachments, you must file your corrected paper claim to BCBSNE with the attachments.
Do not submit corrected claims using a Reconsideration Request form.
Please refer to GP-X-039 Corrected Claims for more information.
Effective Feb. 1, 2025, dispensing fees will no longer be considered content to the hearing aid purchase and, if billed, will no longer deny as provider contractual write-off.
The Risk Adjustment Department at BCBSNE will be transitioning to a new platform for requesting medical records. This transition will occur over the next several months.
The current fax number where Risk Adjustment Medical Record requests can be returned is 402-548-4664, this line will remain open during the transition time.
The new Risk Adjustment medical record request letter will include a portal with an individual access code for healthcare provider offices to upload documents as well as an option to fax medical records to our new fax number 402-506-7032.
We appreciate your patience as we transition to this new platform.
Effective Jan. 1, 2025, BCBSNE no longer accepts paper (faxed or mailed) timely filing override requests. As part of our ongoing transition to paperless processes, all timely filing override requests must be submitted via NaviNet.
Please note that we will no longer process or return paper timely filing override requests received via fax or mail.
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.
Please be sure to update your professional license information in the personal information section in the CAQH Provider Data Portal.
For those applying for initial credentialing please have your license number before applying. BCBSNE is returning applications if licenses are not included on the application. If you have already submitted your application, please reapply when you receive your license. Previous board certification will still be required.
Behavior Analysts who are due for recredentialing, without a license on file, participation will be terminated until a new application with license and previous board certification will be needed.
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.
Nearly a year ago, as a result of the Change Healthcare cyberattack that suspended claims processing services for many providers, BCBSNE extended financial assistance, facilitated transitions to new clearinghouses and allowed timely filing extensions when appropriate. Please note that as of Oct. 24, 2024, we have returned to adhering to contractual timely filing limits for all providers.
Effective Jan. 2, 2025, BCBSNE will be retiring the Urgent Radiology Preauthorization Request phone number 402-982-8870 or 888-263-3870.
Please update your records accordingly and direct all future radiology-related inquires via NaviNet.
We appreciate your cooperation and understanding.
When patient care extends into the new year, following our Split-Year Claim Submission policy ensures your claims are not rejected, returned or delayed due to billing errors.