When submitting Medicare Advantage claims, providers will need to ensure:

Rendering NPI number is not populated in box 24J / 837 loop 2310B segment NM1 and/or 2420A segment NM1 if the number is the same as the billing NPI
If a provider is a sole proprietor – only submit the NPI in box 33A / 837 loop 2010AA segment NM1
This is a situational rule and is not a requirement
If a claim is submitted with the same NPI in both box 24J and 33A the claim will reject
Submit claims with a street address in the billing address field
Claims are not accepted with a PO Box in the billing address field


Any outstanding claims not submitted per above instructions will need to be resubmitted.

Did you know if you submit claims with your patient account number this available in NaviNet?

This is not a BCBSNE assigned number—this is the number from your EMR/records. Our CSC team will no longer provide this information instead we will direct you to NaviNet or to reference your own system.

Blue Cross and Blue Shield of Nebraska (BCBSNE) requires a refund offsetting process for in-network providers. If you identify a claim overpayment has been made, please follow the claims adjustment process.

Please do not send a check/payment as the recoupment will be satisfied with a refund offset.

Please reach out to our Refunds Department at 800-562-3381 with any questions.

Note: If the offset is due to an overpayment of a Federal Employee Program (FEP) claim, offsetting will only occur on other FEP claims. We will not offset overpayments on FEP claims with claims that are non-FEP.

Read the Refund Offsetting (GP-X-095) policy.

As mandated by the Nebraska Department of Insurance, effective Sept. 1, 2023, all credentialed providers who are eligible to provide telehealth services (see policy GP-X-016, Telehealth) will be reimbursed at 100% of the in-person allowed amount. 
 
BEHAVIORAL HEALTH PROVIDERS: LB487 effective Sept. 1, 2021, mandated that in-network telehealth behavioral health services to be covered at 100% of the in-person allowable amounts.  Behavioral health services provided via telehealth will continue to be reimbursed at 100% of the in-person allowable amounts.
 
Providers exclusively delivering telehealth services must live in the state of Nebraska, be a member of a credentialed Nebraska-based PHO or employed by a licensed or credentialed facility in Nebraska. Providers will also still need to meet the credentialing criteria that is available at Credentialing Information for Providers.

BCBSNE Member ID cards are available on NaviNet. Providers requesting timely filing overrides for member ID will be required to show system notes proving the member presented without insurance and/or a different insurance. Per policy GP-X-046 for an exception to be considered, we must receive proof of no member insurance at the time of service or proof that attempts were made to obtain insurance and/or payment.

In addition, if a member provides insurance other than BCBS insurance and you receive notification from that insurance the BCBS is primary, this is considered a COB situation and should be submitted on a reconsideration with the primary recoupment or denial. Do not send as a timely filing because these are being returned to you and delaying your ability to have the claim processed correctly.

We are excited to announce, because of our continued enhancements in NaviNet^®, we will begin to improve the way providers request remittances advices (RAs). RAs are and have been available on NaviNet for some time. 

Effective Sept. 1, 2023, providers will no longer need to contact our Customer Service Center (CSC) for 

• RAs – Remittance Advice is available on NaviNet
• Checking claim status less than 30 days from submission 

In addition, inquiries should be sent via NaviNet Claim Investigation. The previous online inquiry process to Customer Service will only be available for Federal Employee Plan claim inquiries.

Please be advised our CSC team members will redirect providers to NaviNet and will not be providing RAs nor will they address questions for claims statuses less than 30 days from submission.
 
In the event your RA is not available on NaviNet:

• Review our Happening Now to see if there is an already known issue
• Reach out to your clearinghouse for a copy
• Email ProviderExecs@NebraskaBlue.com with the payment number and payment amount

^{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska}

As we continue to enhance our self-serve tools, we are excited to announce a new feature to NaviNet called Claim Appeal! Submitting an Appeal, Reconsideration, or Claim Timely Filing Dispute is now easier!

Instead of filling out the forms from our provider website and attaching them to claims to submit your request, please go to your claim status details, click on the  button, and select the Type and Reason for your request. You can add free-form text, attach any supporting documentation (in PDF format), and submit the request.

For risk optimization requests, the “attach” functionality has been disabled, please follow the submission instructions on the request letter. 

BCBSNE will respond to your request when a resolution has been reached. You cannot track the status of your appeal or reconsideration in NaviNet, unless you start the process in NaviNet.

For help with Appeals, our Help Guide and video is available at Find a Form for Providers.

For help with Claims Investigation, our NaviNet Guide is available at Eligibility & Claims Information for Providers.

When a resolution is reached, the letter will be available in the Document Table located directly below the "Claim and Service Line Details" section of your Claim Status Details screen.

Please note, if other carrier information needs to be reviewed, please select Reconsideration:

• Subrogation (reminder, this is not an exception to the timely filing limit. Timely filing requirement starts on the date of care) 
• Coordination of Benefits (timely filing is 120 days from the date on the primary payor’s EOB, which must be included)  
• Worker’s Compensation (timely filing is 120 days from the date on the worker’s compensation carrier letter, which must be included)

If reconsideration requests are submitted via the timely filing form, the request will be redirected back to the sender to complete the reconsideration form.
 
Please allow the following timeframes for processing your request:

Appeals up to 30 working days
A request when a provider or member disagrees with a denied claim/service.

Reconsiderations up to 45 calendar days 
A request to review a claim with additional information not previously provided.

Claim Timely Filing Disputes up to 30 calendar days
A request to override a claim denied for timely filing.

If, after this time, you have questions about your request, you can use the new Claim Investigation functionality to send an inquiry to BCBSNE by clicking the  button on your claim.

We understand that the difference between Appeal and Reconsideration requests can be confusing. If you selected the incorrect type, your request will be processed and will not be returned to you. Please note, timely filing dispute requests need to be submitted on the appropriate form or they will be returned

We encourage ALL providers, including our dental providers, to use self-serve functionality first; our team will redirect when other self-serve tools are more appropriate.

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BCBSNE advised of participation requirements in the 4th quarter of 2022 via emails, UPDATE newsletter, Happening Now as well as the provider email blasts. Not completing the steps for participation would result in termination from the network. Providers were again advised on Jan. 12, 2023, to update their NPPES status to sole proprietor or obtain a Type II NPI to avoid termination on or after Jan. 31, 2023.

If you have NOT completed the steps below – you have been termed or are subject to termination.

How to Stay in Network:

• If you are a sole proprietor, log in to https://nppes.cms.hhs.gov/ and select: 
  • Option 1"YES" I am a sole proprietor. 
• If your clinic has multiple practitioners, update NPPES and select: 
  • Option 2 "YES" I will be getting a Type 2 NPI
  • Option 3 "NO" I prefer to go out-of-network
• Send an email to HealthNetworkRequests@NebraskaBlue.com to indicate which option you have chosen for your NPI.

Currently – anyone termed for not updating their NPI has claims on hold and/or claims have been rejected, returned, denied or processed out-of-network. 

BCBSNE has made the business decision to hold all claims for these specific providers beginning Monday, Jul. 31, 2023, through Sept. 1, 2023.

Once a provider has notified us by sending the email to HealthNetworkRequests@NebraskaBlue.com we will release claims once validation is complete.

Effective Sept. 1, 2023, all claims will be released. Any provider that has not updated their records will be fully terminated and claims will reject, return, deny or process out-of-network.

New providers joining the BCBSNE network are required to follow the same guidelines.

To comply with regulatory requirements, BCBSNE has established appointment availability standards to ensure timely access to care for all members. In March 2023, a telephone survey was conducted with approximately 2,200 providers to evaluate compliance with the standards. Many providers did not demonstrate compliance with urgent, emergent, or after-hours access standards.

As a reminder, in-network providers agree to maintain appointment availability standards. To ensure compliance with each of the standards below, your office must be following at least one of the items noted in the Compliance column for each appointment type. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP). Please note that the next survey is scheduled for the fourth quarter of 2023. Please ensure you are in compliance with at least one of the following:

For a complete list of the appointment availability standards, please go to NebraskaBlue.com/Providers/Credentialing. 

Appointment Type	Standard	Compliance
Urgent	Within 24 hours	Appointment can be scheduled within 24 hours Available for patient to walk-in and receive care  Triage is available with a nurse or other provider  Patient is instructed to go to the urgent care, nearest ER, or call 911
Emergent	Immediate	Available for immediate face to face medical attention Available for patient to walk-in and receive care Triage is available with a nurse or other provider  Patient is instructed to go to the urgent care, nearest ER, or call 911
After-hours access	24/7 via phone	Live party is available after-hours Recorded message includes instructions on how to reach a live party Recorded message provides emergency instructions to go to nearest ER or call 911

Starting on May 24th and every Wednesday going forward, Blue Cross and Blue Shield of Nebraska Customer service will be closed from 9:00am to 10:30am central time for an all-department meeting. This time will be used for Learning and Development for our employees to ensure we continue to deliver the best service possible. Thank you for your understanding.

As a reminder – Self Service Tools are available for use:

• NaviNet^® is available by clicking here NaviNet.Navimedix.com/Plan-Central/BCBSNebraska#/
  •  Member eligibility details are based on the date entered as the service date. Coverage will show as inactive if the date of service is prior to the effective date.
• Claim status inquiries and processing details are also available on Navinet. 
  • If you need additional assistance with claim status inquires you may use our new Claims Investigation feature. Please allow up to 5 days for our response.
• The automated voice system is available via 1-800-635-0579. 

 

_{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska.}

 At BCBSNE, we are working to help our members with complex medical conditions get the care they need in the most cost-effective way.
 
The biologic medication Humira® (adalimumab) will begin to have multiple cost-effective biosimilar alternatives available starting in July 2023. Biosimilar products can be utilized in most clinical circumstances as the reference product.
 
Starting Jul. 1, 2023, we are adding the biosimilar products AmjevitaTM (adalimumab-atto)* and Cyltezo® (adalimumab-adbm) to our preferred product list. This means that BCBSNE will have coverage, if medical policy criteria is met, for two biosimilars in addition to the reference product. For reference, Cyltezo is an FDA approved interchangeable product to some Humira products.
 
For questions regarding coverage of adalimumab reference and biosimilar products, please refer BCBSNE members to call the Member Services department at the number on the back of their member ID card.
 
*NDCs starting with 55513 

ID Card Updates

Beginning in July 2023, member ID cards will be updated to a new format. The card's contents will remain unchanged, except for an updated Pharmacy Help Desk phone number for all ID cards as well as the addition of claim filing instructions to Medicare Supplement and dental-only ID cards.

Updated ID cards will not be mass issued; instead, new cards will be issued as members make plan changes that would trigger a new ID card (adding a new member, changing network, etc.) or for new members. 

Below is a sample of a new ID card with the format changes highlighted. Items highlighted in yellow are in a new spot; items highlighted in red are new/updated.    

 

Medicare Supplement

Dental

Digital Temporary ID Card

In addition to the format changes, beginning in August 2023, newly enrolled members will have access to a digital temporary ID card. This ID card will have limited details.

To verify benefits and eligibility, please login to Navinet®*, call our automated voice system at 1-800-635-0579, or contact Customer Service.

*Member eligibility details are based on the date entered as the service date. Coverage will show as inactive if the date of service is prior to the effective date.

 

As we continue to enhance our self-serve tools, we are excited to announce a new feature to NaviNet called Claims Investigation! This replaces the online claim inquiry process with Customer Service on our website, NebraskaBlue.com.

When logging on, simply perform a Claim Status search and look for the new “Investigate” button

• This is located the top of the claim status results page
• The application will keep a running history on any inquiries and responses related to the claim
• This is available to anyone in your office with a NaviNet account 
• More detailed instruction will be available here Eligibility & Claims Information for Providers next week or on our Provider Academy page (coming soon)

If our customer service team has sent documentation in support of the inquiry, there will be a new document table where the attachment can be accessed. 

• The document table will be located at the bottom of the Claim Status Details screen
• This is below the "Claim and Service Line Details" section

We encourage ALL providers including our dental providers to use self-serve functionality first, our team will be redirecting when other self-serve tools are more appropriate.

^{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska}

On May 25, 2023, BCBSNE implemented a change in our mail processing.  This change impacts the time it will take for providers not signed up for EFTS and ERAs to receive paper check payments and paper remits.

Previous Process:

• Checks and remits were received within 3-5 business days

New Process:

• Checks and remits will be received within 5-7 business days

As we continue to enhance our digital delivery channels, paper transactions will decrease.  To get ahead of future transitions and avoid the extended time it will take to receive the check and remit, providers can sign up for EFTs and ERAs by completing the forms found on NaviNet and submitting to HealthNetworkRequests@NebraskaBlue.com.

• Electronic Funds Transfer (EFT)
• Electronic Remittance Advice (ERA)

If you have questions, please contact your Provider Executive. 

Effective May 15, all forms used to update demographic and practice data will only be available only through NaviNet via the Administrative Updates/Secure Forms. This includes the forms to update EFT information. You can access the forms under the Resources section. 

• NPI Notification
• Electronic Funds Transfer Enrollment Request 
• Provisional Provider Form 
• Extend-Transfer Existing Agreements
• Change of Address Form 

If you do not have a NaviNet account, please visit https://connect.NaviNet.net/enroll to begin the registration process. All participating BCBSNE health care and dental providers can enroll for access. 

BCBSNE is committed to ensuring claims and adjustments are handled as timely as possible. To create a more efficient handling of COB, Worker’s Compensation and Subrogation adjustments, we are removing these as options from the timely filing form beginning May 15. Providers should use the reconsideration form found on Find a Form for Providers and submit via NaviNet or follow the steps on the bottom of the reconsideration form. 

If you do not have a NaviNet account, please visit https://connect.NaviNet.net/enroll to begin the registration process. All participating BCBSNE health care and dental providers can enroll for access.

Effective May 1, 2023, providers exclusively delivering telehealth services must live in the state of Nebraska, be a member of a credentialed Nebraska-based PHO or employed by a licensed or credentialed facility in Nebraska. Providers will also still need to meet the credentialing criteria that is available at Credentialing Information for Providers.

Beginning April 1, 2023, we will no longer add new locations or new groups as part of our recredentialing process. 

This will help to align our ask for providers to follow current processes when adding or updating information for providers currently in our network.

Please follow the process under the Administrative Updates for Providers page using the appropriate form to add/update. 

Notification will be sent back to the credentialing contact advising them of the process to not add locations upon recredentialing.

BCBSNE is aware of the Norditropin shortages in the market. Our response to this situation is below.

Effective immediately, our preferred products will be Norditropin and Genotropin. Our formulary and medical policy will include another growth hormone product. 

Genotropin provides another clinically appropriate growth hormone therapy option. 

BCBSNE is actively mitigating the need for another preauthorization submission to use Genotropin. Updating the overrides in our system may take a couple days, but we are working to have these updated quickly. Currently, we do not need another request from providers to use Genotropin. 

We will update this page once we have finalized our updates and advise if anything changes. 

On September 6, 2022, BCBSNE advised all providers of the below information. It is imperative to be aware of the January 31, 2023, deadline that is quickly approaching, your attention to this matter is appreciated.

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, or for sole proprietors to indicate as such on NPPES. This is required to align with Blue Cross Blue Shield Association standards. 

Options For NPI Registry:

• If you are the only provider practicing at your location, please make sure that NPPES is updated to reflect your individual NPI as “Sole Proprietor”. 
• If you are the only provider practicing at your location, but eventually want to expand, please apply for a Type 2 (Organizational NPI) for your location/group to bill under.
• If you have multiple practitioners practicing at your location, regardless of how often, you must apply for a Type 2 (Organizational NPI) for your location/group to bill under.

How to Update NPPES:

• Go to https://nppes.cms.hhs.gov/ to apply or update existing information.
• More information on NPI found at:
  • NPPES FAQs — NPPES Documentation (hhs.gov)
  • NPI: What You Need to Know (cms.gov)      

How to Update Record with BCBSNE:

• Send an email to HealthNetworkRequests@NebraskaBlue.com to indicate which option you have chosen for your NPI (If you are an existing provider that needs to update records).

Effective January 31, 2023- Any provider that has not updated their records will be subject to contract termination. Any new providers coming in are required to follow the same guidelines.

Moving forward, 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. 

Effective Jan. 1, 2023, member contracts have been updated to note this change:

Non-covered services include:
Dietary counseling, except as part of nutritional management for diabetes, certain conditions covered under ACA Preventive Services and eating disorder.

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
  
   

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

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

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 »