Happening Now

As a reminder, the Consolidated Appropriations Act (CAA) requires that certain provider directory information be verified every 90 days. BCBSNE participating providers are required to verify and attest to the accuracy of their information in the CAQH Provider Data Portal. The information must be attested to every 90 days, even if the data has not changed since last verified.

Under the CAA, BCBSNE is required to remove providers from our directory whose data we are unable to verify. If you do not complete the attestation in CAQH, and we are unable to verify your information, you may be removed from the directory.

For more information about verifying your information in CAQH, please visit CAQH Provider Data Portal.

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.

TriWest is experiencing an ongoing issue affecting remittances and is currently at the highest level of escalation.

There is no estimated time for resolution at this moment. Continue to check back here for updates. 

Important Updates:

• April 29, 2025: The TRICARE West Region Referral Waiver has been extended through June 30, 2025.

Providers should use the following TriWest resources:

• TRICARE West Region Referral Waiver Approval Letter 4-2-25
• 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 at 1-888-TRIWEST (874-9378)
• Click here for help navigating their Provider IVR
• Fax: 866-852-1893 (for same-day, urgent referrals, fax detailed information)

BCBSNE can assist with the following:

• 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
• Provisional providers-excluded from 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.

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.

We have noticed an increase in faxes requesting the status of preauthorization reviews. This is unnecessary and is impacting the efficiency of our fax system. To streamline the process, please follow the steps below to check the status of your preauthorization requests.

Checking Status via NaviNet^®
To check the status of a preauthorization request submitted via NaviNet, please follow these steps:

1. Log in to NaviNet.
2. Under Workflows for this Plan, select Preauthorization or Precertification.
3. Select the ordering provider and click the submit button.

Note: The rendering facility will be able to view the status only if the ordering provider identified the rendering facility when entering the request in NaviNet.

1. Click the Authorization List icon from the menu on the left side of the screen to view the authorizations.

For Preauthorization Requirements
Reminder: To verify if preauthorization is required for a specific procedure code you must utilize the medical policy tool.

Out of Area Members
For out of area members, please select Pre-Service Review for Out of Area Members Workflows.

Additional Help
If your preauthorization request was initially faxed in, you may contact Customer Service at 800-635-0579, Option 5.

For further assistance, please visit our Provider Academy. An eLearning tutorial is available in NaviNet Tips and Tricks.

By following these steps, you can efficiently check the status of your preauthorization requests, reduce the number of unnecessary faxes, and verify Medical Policies. Thank you for your cooperation!

From February through May each year, BCBSNE conducts medical record reviews to gather essential Healthcare Effectiveness Data and Information Set (HEDIS) measurement quality data for our members. This process is crucial for assessing the quality of care provided to our patients.

Data Collection Process:

Commercial Members: Data is collected using Reveleer^®.

Medicare Advantage Members: Data is collected through Datavant Health.

Both Reveleer and Datavant Health will reach out to your clinic to request specific clinical details that may not be included in claims data, such as: Blood pressure readings, HbA1c lab results and Colorectal cancer screenings.

Your cooperation in providing these records is vital. It not only helps us meet our quality goals but also enhances the overall health of our members — your patients.

Contractual Obligations:

As a participating provider, your contract includes provisions for supplying requested records to BCBSNE or our third-party vendors at no charge. We aim to minimize disruptions to your office workflow; therefore, prompt responses to these requests will reduce the need for follow-ups.

Thank you for your assistance in this important initiative. Your support is invaluable in helping us successfully complete our HEDIS reporting.

For more information on HEDIS, please visit NCQA.org.

We are pleased to inform you of an important update to our Radiology/Imaging policy that will benefit your practice and your patients. As of March 15, 2025, policy IV.81 has been revised to streamline access to essential health services. This change does not apply to our Medicare Advantage plans.

Key Update:

These CPT codes will no longer require preauthorization or medical review for our commercial plans.

• 78451 - Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
• 78452 - Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
• 78453 - Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
• 78454 - Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

What This Means for Your Practice:

• Simplified Process: You can now perform Myocardial perfusion imaging without the need for preauthorization or medical review, allowing you to provide timely care to your patients.
• Reduced Administrative Burden: This change minimizes the paperwork and administrative tasks associated with preauthorization, enabling you to focus more on patient care.
• Enhanced Patient Outcomes: By facilitating easier access to this important screening tool, we aim to support early detection and better health outcomes for your patients.

We are committed to continuously improving our services and policies to better support your practice. If you have any questions or need further assistance, please do not hesitate to contact our provider support team. Thank you for your continued partnership and dedication to patient care.

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.

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.