Happening Now

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Please continue to watch Happening Now for updates. 

Blue Cross and Blue Shield of Nebraska has decided to align with CMS’s MPPR guidelines and apply the MPPR for therapy and radiology procedures.  These changes will take place December 1, 2022.

Non-Nebraska Outpatient and Professional Claims

For outpatient and professional claims with charges incurred during different years, must be submitted on separate claims. This requirement will be the same each year end for split year claims.

Claims for non-Nebraska members that are not split will reject back to the provider upon submission.

For example:                                                                                                                                                                            
If dates of service are from 12/15/2022 to 1/15/2023:

  • Submit charges incurred from 12/15/2022 – 12/31/2022 on one claim
  • Submit charges incurred from 1/1/2023 – 1/15/2023 on a separate claim

Claims that are submitted with charges incurred during both years on the same claim will be rejected back to the provider to split the claim. 

Institutional Inpatient Claims

For inpatient* institutional claims, it is no longer required to split the entire claim for non-Nebraska members, however, it will be required to split the R&B charges per calendar year.

Claims for non-Nebraska members where the R&B charges are not split per line by calendar year, will reject back to the provider upon submission.

For example:
If dates of service are from 12/15/2022 to 1/15/2023:

  • Submit R&B line for 2022 dates of service on another line
  • Submit R&B line for 2023 dates of service on another line

Claims that are submitted with the R&B on one line for multiple years, will be rejected back to the provider to split the R&B lines.

*Inpatient includes acute care hospital, psychiatric hospital, rehabilitation hospital, skilled nursing and swing-bed

To become a contracting BCBSNE provider all applicants must complete the credentialing process and have a signed agreement on file, prior to be accepted into the network. New practitioners wishing to join BCBSNE can complete the CAQH application at CAQH.org. For more information regarding credentialing requirements and/or to request a provider agreement, please visit NebraskaBlue.com/Providers/Credentialing

Effective November 6, 2022, BCBSNE requires all providers that are not sole proprietors to have a Type 2 NPI. This is required to align with Blue Cross Blue Shield Association standards. 

If you do not currently have a Type 2 on file, you can apply at https://nppes.cms.hhs.gov/. Providers without a Type 2 NPI on file will be subject to contract termination. Please ensure you are keeping all your data current in NPPES. The Blue Cross Blue Shield Association does verify all BCBSNE provider data against NPPES to confirm taxonomy and NPI information is valid and accurate. 

 

Today we are announcing a change to the way we process claims with NDC (National Drug Code). Through our interactions with you and internal review, BCBSNE recognizes this was a barrier to the ease of doing business with us.

This change will be effective with dates of service August 1, 2022, for BCBSNE, non-Nebraska and FEP In Network (INN) claims.  

Previous Process:

  • Claims returned for missing, invalid, incorrect NDC

New Process: 

  • Specific NDC line item will deny if missing, invalid, incorrect, etc. with message code 
    • Denial message code PC 33 (for provider) – The National Drug Code (NDC) is missing or invalid
    • RARC code will be M119 Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC)
    • CARC code will be PR or CO 16 dependent on if provider is PAR or nonPAR
  • Other line items (if any) on the claim will process if errors are not present 
  • If claims are denied for NDC, providers can resubmit claims with corrected NDC or submit reconsiderations as appropriate 

Claims returned with DOS 8-1-22 or after can be resubmitted – but will need to be submitted within timely filing guidelines. 

Effective Sept. 1, 2022, Blue Cross and Blue Shield of Nebraska requires modifier QW on CLIA-waived lab tests. Claims submitted for reimbursement without a QW modifier will not be reimbursed.

In compliance with the Consolidated Appropriations Act of 2021, providers are required to review and update their information in our provider directory at least every 90 days.

  • Beginning 10-1-22 ALL providers (including dentists) can begin to review directory info using NaviNet
  • Providers NOT using NaviNet will need to sign up. Go to Connect.NaviNet.Net/Enroll to register. 
  • More info is available in the July Update
     

Effective September 1, 2022, Educators Health Alliance (EHA) will move to a new prescription drug list to keep medications affordable. Communications to all members started in March; impacted members received formal letters from BCBSNE on July 1, 2022. 

This change will also impact the below diabetic supplies.  Beginning September 1, 2022, these supplies will be covered under the medical benefit vs the pharmacy benefit.

  • Autosoft Infusion Set
  • MiniMed Infusion Set
  • Paradigm Infusion Set

Also on September 1, 2022, all EHA members will receive new ID cards with a QR code so providers can easily access their benefits; ID numbers will remain the same. EHA member ID cards begin with EHN.

The prescription drug list (PDL) can be found here

 
The details
  • Professional claims on hold
    •  For claims that were being held when received between July 8-12, those claims have been released from hold.
  • Fee schedules in NaviNet
    • For providers who are not affiliated with a PHO and receive their fee schedule via NaviNet, BCBSNE has resent the 7/1/2022 fee schedule to NaviNet.
    • Please make sure that the fee schedule that is used is the fee schedule with the received date of 7/20/2022.
    • Example from NaviNet, Practice Documents:
      Navinet Example

If you have any questions, please reach out to your Provider Executive.

The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. 

  • In Q4 2022, we are implementing a new process using NaviNet, that will allow you to review your provider directory information to ensure we have the most current information available to our members.
  • For those providers not enrolled in NaviNet, we strongly encourage you to register as soon as possible.
    • Go to https://connect.NaviNet.net/enroll to begin the registration process
    • All participating medical and dental providers can register for a NaviNet account
    • NaviNet is a secure self-service provider portal for verifying benefit and eligibility information, checking on claim status, and submitting prior authorizations

More information will be coming on the process of reviewing your directory information in NaviNet. Please continue to review your information regularly and let us know as soon as possible if any of your information has changed. 

If updates are needed, visit the Administrative Updates for Providers page for instructions and forms. We appreciate your help ensuring our members have the most up to date information. 

For PHO groups handling their own credentialing processes – only the below steps will apply:

  • BCBSNE will be requesting submission of a full roster every 90-days
  • Additional communications will be sent on the timeline for this request
  • Your Provider Executive will be reaching out with more information

You will notice changes to the recoupment initiation notification and offsets displayed in your 835s and EOPs. Previously they displayed the claim the offset was FROM, rather than the claim the offset was FOR. The document below reflects the process in place.

Changes to 835 and EOP:
  • Recoupment offsets will display immediately
  • Recoupment offsets will not happen for a minimum of 30 days after notification
  • When money is deducted from a future payment; it will be important to reference the previous 835/EOP for details. See the Provider Level Adjustments for more information »
  • Once a claim has been adjusted/voided, the adjustment/void and the offsetting of the recoupment will be reflected in the next 835 and/or EOP
With HealthRules:
  • FEP claims will offset immediately
  • Partial recoupments
  • Dental recoupments
Guide to Understanding the Adjustments
Notes include:
  • Where to find the adjustments on the claim
  • An example of the new change where positives become negatives and negatives become positives
  • How to tell if the adjustment affects the claim
  • An example of a message indicating the amount retracted from the adjusted claim

Questions? Reach out to your Provider Executive Team »

BCBSNE has made the decision to deny PLA CPT® codes submitted by providers when appropriate.

  • If providers believe the denial is inappropriate, they should submit an appeal and include records that support the use of the proprietary laboratory
  • Alternative CPT codes may be available and are encouraged to be used in place of the PLA codes when appropriate

The NYC Medicare Advantage Plus plan is not being implanted on April 1, 2022.  All retirees will remain in their current plans until further notice.

Effective February 23, 2022, when performing an eligibility and benefits search in NaviNet, using the member ID # will always return the best match. However, providers can now do a search for a BCBSNE member or BCBSNE Medicare Supplement member without the member ID.

Providers can now do an eligibility and benefits search for a BCBSNE member without entering an ID #. First name, last name and date of birth are required to bring back results, this includes BCBSNE Medicare Supplement members. 

NOTE: In the event the BCBSNE member has more than one BCBSNE ID#

  • No search results will be returned, and an error message will be displayed
  • If a BCBSNE member has more than 1 BCBSNE ID #, the ID # must be included to return results
  • Reminder the SSN can continue to be used in the ID # field as an additional way to search
Searching NaviNet without Member ID

We have exciting news for our contracting providers! 

Beginning January 1, 2022, you will receive direct payment as well as remits for covered services in accordance with your provider agreement.  

Providers who are in-network with NEtwork BLUE, but out-of-network with one of the regional networks (Blueprint Health or Premier Select BlueChoice), will now receive the payment and remit rather than directing payment and remit to the member. 

Out-of-network provider payments will be paid to the provider and processed in accordance with the member’s out-of-network benefits.

Several of our groups have moved to a new platform this year.  This move includes a new prefix, new plan code as well as possible new ID number.  

Please make sure you are requesting the MOST current benefit card from the member. 

When attempting to get a pre-authorization or pre-certification for non-Nebraska members, there a few things to know:

  • Providers seeing members with Highmark, other non-Nebraska branded cards or members with the below information should not choose BCBSNE’s preauth tool or medical policy tool 
    • Cards with plan code 363/865
    • Member claim submission address on back of card (not Nebraska)
  • On NaviNet make sure to choose the correct BCBS plan (see examples below)
  • Information (phone numbers) is on the back of the member’s card which will help you obtain the requirement for pre-authorization/pre-certification
  • Do not turn these members away or cancel services without at least calling the number on the back of the member card

Pre-Authorization/Pre-Certification for Non-Nebraska Members

Beginning March 1, 2021 ANY corrected claims submitted with a recon will be returned. Corrected claims should be submitted electronically.

If they cannot be submitted 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 form, it will be returned.

More information can be found in section 8 of our General P&P. 

This is a reminder that remits will be received by the Clearinghouses within 72 hours from the time of the weekly payment. Reminder, remittance information is available via NaviNet. If you are unable to retrieve your remittance advice after 72 hours, please check NaviNet and your clearinghouse, if applicable.  

If you are unable to locate remits after using the steps above, please email your request to ProviderServicesOperationsSupport@nebraskablue.com. Our teams will research and follow-up within 10 business days.

Please include:
  • Provider name, NPI, Tax ID
  • Details on the payment
    • Check number (if applicable)
    • Check amount (if applicable)
  • Date missing
  • Contact information

Blue Cross and Blue Shield of Nebraska continues to work on improving the tools available to our providers. The following can now be obtained for non-Nebraska BCBS members:

  • Accurate claim status 
  • Correct claim ID
  • Applicable check number/EFT with working remit link

We have adjusted our process to ensure allowed amounts are reflected on the 835s.  Providers should see this change reflected on the 835s moving forward. 

We would like to bring awareness when BCBS is not the primary payer.  When BCBS is secondary, the allowed amount displayed on the 835 reflects what is allowed AFTER the primary insurer processes the claim.  Please see some examples below:

Example 1: 
  • Primary allows $100 and pays $85 
  • 835 will reflect $15 as the allowed amount ($100-$85 = $15)
Example 2: 
  • Primary allows $100 and pays $0
  • BCBSNE allows $120 but 835 will reflect $100 as allowed amount of primary

Currently providers are receiving CO 45 (charges exceed contracted arrangement) remark code on remits. This is not a separate discount. Providers can ignore this code as they would receive the correct adjustment amounts from Medicare.

BCBSNE introduced the requirement for taxonomy codes on electronic claims in 2019. Our May UPDATE provided additional information. Beginning March 16, 2020, we will require both electronic and paper claims to be submitted with the taxonomy code.

Currently, our system is rejecting electronic claims missing the taxonomy code, but we have been processing paper claims. Beginning Monday, March 16, 2020, we will also return paper claims. Making this change will allow us to process claims more efficiently.

For additional information, please see Claims FAQs »