Happening Now

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 Executive. 

Effective Aug. 1, 2025, the high dollar claim threshold will be adjusted from $100,000 to $75,000. 

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? 

• New Threshold: Claims equal to or exceeding $75,000 will now be subject to high dollar review.
• Previous Threshold: $100,000
• Effective Date: This change applies to any discharges on or after Aug. 1, 2025.

What you need to do: 

•  Ensure your billing and administrative teams are aware of this change.
• No action is required for claims under $75,000 or for discharges prior to Aug. 1, 2025.

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

Providers should use the following TriWest resources:

• Need quick tips? Access the How to Submit Referrals and Authorizations Quick Reference Guide.
• Need training? Go to the TriWest Learning Center in Availity for referral and authorization webinars and on-demand options.
• Talk to a Customer Service Representative: Call 1-888-TRIWEST (874-9378).
• Provider IVR Navigation: Click here for help.
• Fax: 866-852-1893 (for same-day, urgent referrals, fax detailed information).

BCBSNE Assistance:

For details on how to add providers to the TRICARE roster, view the credentialing variances, and accreditation requirements, please refer to our TRICARE Network Providers FAQ page.

BCBSNE continues to further our paperless transition with a shift toward electronic remittance advices and payments.

• Effective Oct. 1, 2025, paper remittance advices will be discontinued. Providers can receive 835s by signing up with a clearinghouse or accessing remittance advices in NaviNet^®.
• Effective Oct. 1, 2025, the option to receive paper checks will be discontinued. Providers currently receiving paper checks will need to fill out an electronic funds transfer (EFT) form to receive electronic payments.
• Forms available on NaviNet: The necessary forms for signing up for EFT and enrolling in the electronic remittance advice service are available under the Administrative Updates/Secure Forms link on NaviNet. Please complete these steps in advance of Oct. 1, 2025.
• Exception for dentists: Due to limited self-service options in NaviNet, dentists can continue receiving paper remittance advices if they cannot enroll with a clearinghouse.

Paper remittance advices and paper checks will no longer be an option for newly credentialed providers effective July 1, 2025.

When an Advanced Provider Inquiry is resolved, the case will be closed. You will receive an email notification indicating its closure. If you have any further follow-up questions, please submit a new API request. Responses will not be provided to closed cases.

Starting soon, providers will notice a streamlined process for submitting appeals, timely filing requests, and reconsiderations via NaviNet. The current system, which requires selecting a “type” (Appeal, Recon, or Timely Filing), will be 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 aim 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.

Providers often need to decide between submitting an appeal or a reconsideration request for reimbursement issues. Here’s a simplified guide to help you choose the right process.

Reconsideration requests

Use a reconsideration request to review the reimbursement level of submitted charges. This is only available if a claim has been processed and remittance advice issued. Reasons for reconsideration include:

• Pricing review
• Worker’s compensation
• Contract pricing
• Medical record review for code edits/denials
• Other insurance information (with the exception of Medicaid – we do not coordinate benefits with Medicaid)
• Modifier submission issues

Submission guidelines:

• In-network providers: Submit via NaviNet^®
• Out-of-network providers: Submit via NaviNet or the reconsideration form at NebraskaBlue.com/Providers/Find-a-Form
• Complete the form fully, including claim number and member ID
• Check the applicable box and describe the issue concisely
• Include relevant documentation only
• Issues like preauthorization or medical necessity denial should be sent as appeals

Appeals

An appeal is a request to review a denial that you disagree with. Examples include medical necessity, medical policy, and investigational determinations.

What Is considered an appeal review?

• Medical necessity
• Investigative
• Cosmetic
• Contract exclusions
• Contract Exclusion – Hair Loss, Obesity or Fertility
• Contract Exclusion - Other
• Duplicate
• High Dollar Prepayment Review
• No preauthorization obtained
• Pre-existing conditions
• Medical emergency
• Medical vs. dental
• In-network vs. out-of-network

How to submit an appeal

Submit appeals, timely filing requests, and reconsiderations via NaviNet. Forms for out-of-network providers are available on our Provider Forms page.

Choosing the right process ensures efficient handling of your claims and better outcomes for everyone involved.

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.

It's crucial to include the correct telehealth-approved taxonomy code on your claim line items for successful processing. This ensures your claims are recognized as telehealth services and processed correctly.

Key Points:

• Include the taxonomy code and necessary modifiers on the claim line: Add the telehealth taxonomy code directly on the claim line item and use modifiers like 95 (synchronous telemedicine) or GT (interactive audio and video) to specify telehealth services.
• Match credentialed information: Ensure the taxonomy code matches the one credentialed and approved by BCBSNE to avoid claim denials. For a listing of provider types please reference our Provider Procedures GP-X-016.
• Submit corrected claims if needed: If a claim is denied, submit a corrected claim with the correct telehealth taxonomy code
  For more details, visit Telehealth.HHS.gov.

As part of our Blue Goes Green initiative, non-fillable versions of our online forms are no longer available. This change helps reduce paper waste and improve digital accessibility.

Why the Change?

• Efficiency: Fillable forms can be completed and submitted online, saving time and reducing errors.
• Faster Processing: Online submissions are processed more quickly.
• Accessibility: Fillable forms are user-friendly and easy to complete.

What Providers Need to Know:

• Access: Fillable forms are available on our website.
• Support: Our team is here to help with any questions. 

Thank you for supporting our Blue Goes Green initiative.

In our September 2024 Provider Update, we proudly shared our ongoing commitment to achieving greater payment accuracy. To further this effort, we are thrilled to announce our partnership with Cotiviti, Inc. for periodic post payment reviews of paid medical claims, starting in May 2025. These reviews, including Clinical Claim Validation (CCV), will continue to ensure accuracy and efficiency, now with the expertise of our new vendor, Cotiviti, Inc.

What you can expect

CCV reviews are designed to ensure proper billing practices and promote accuracy and fairness. These reviews may require a copy of the medical records, which will be requested if BCBSNE has not already received them. BCBSNE and Cotiviti are collaborating to minimize the number of medical record requests to providers, streamlining the process for your convenience.

If a claim is selected for review, you will receive a letter identifying the claim(s) and providing detailed information on the guidelines and timeframes to follow. Please note, the historical lookback period follows our contractual timeframe, typically 12 months.

About Cotiviti, Inc.

Cotiviti’s team comprises registered nurses, medical and claims experts with extensive expertise in coding, claims operations and quality. They work closely with clients and medical providers to develop effective strategies, plans and activities that prevent future payment errors and enhance the reimbursement process. Cotiviti is a recognized leader in the industry, partnering with health plans across the United States.

Cotiviti is a Business Associate of BCBSNE as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will perform its responsibilities on behalf of BCBSNE in full compliance with HIPAA requirements.

Your cooperation is valued

We appreciate your assistance in providing Cotiviti’s staff access to the necessary medical and/or financial information to complete these reviews. These requests will be consistent with the methods previously used by BCBSNE, including mail, fax and EMR access.

Thank you for your anticipated cooperation. Please share this information with your staff as you deem appropriate.

Effective May 1, 2025, Blue Cross and Blue Shield of Nebraska (BCBSNE) will introduce a new Advanced Provider Inquiries form on NaviNet. This form is designed to streamline the submission process by collecting all necessary information upfront, enabling the appropriate support team to address the inquiry efficiently and reducing the number of communications required.

Provider Executive Support Areas:

• Escalated Claims Inquiries
• NaviNet System Issues
• Provider Education Opportunities
• Medicare Advantage Rate Letters
• Open Negotiation Requests

Important Changes:

• The new Advanced Provider Inquiries form does not replace the existing Claims Investigations process on NaviNet. Providers must continue to submit Claims Investigation requests before using the new form to contact the appropriate support team.
• As of May 1, 2025, the ProviderExecs@NebraskaBlue.com email account will be decommissioned. Providers will no longer be able to send requests to this email address.

Next Steps: For more information regarding the new process, please watch the Advanced Provider Inquiries eLearning module and monitor this page for updates as the effective date approaches.

Starting May 1, 2025, BCBSNE will implement a new and improved policy for e-consultation services, aimed at streamlining processes and enhancing provider efficiency. This policy update reflects BCBSNE’s commitment to supporting healthcare providers with clear and effective guidelines.

Guidelines for Consulting Providers:

• Utilize procedure codes 99446-99449, 99451, or G0546-G0550 when billing for medical consultations.
• Avoid billing for e-consultation services if a face-to-face encounter with the patient has occurred within the last 14 days.

Guidelines for Requesting Treating Providers:

• Use procedure codes 99452 or G0551.
• These services can only be reported once every 14 days.

Submission Guidelines:

• Apply the Place of Service code that indicates your location when providing the service.
• Note that e-consultation services with Place of Service codes 02 or 10 will be denied.

This policy update is designed to ensure clarity and consistency in billing practices, ultimately benefiting both providers and patients. BCBSNE is dedicated to facilitating seamless and efficient healthcare delivery through these enhanced guidelines. Providers are encouraged to familiarize themselves with these changes to ensure compliance and optimize their e-consultation services.