To help providers submit accurate claims and take advantage of auto-adjudication, Blue Cross and Blue Shield of Nebraska (BCBSNE) continues to rank the top three reasons for claim returns:
The Federal Tax Identification number (TIN) and/or the NPI number for the Provider, Rendering or Referring, is not effective for the date of service.
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
The provider’s name and credentials, Federal Tax Identification number and/or NPI are missing.
Modifier is missing, not legible or is invalid for procedure code.
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.
Peer-to-Peer changes effective Dec. 10, 2024
BCBSNE is updating our peer-to-peer procedure GP-P-003 with the following changes:
Peer-to-peer reconsiderations of not medically necessary denials on prospective and concurrent reviews must now be scheduled within 48-hours of the denial, reduced from the previous 14 calendar days. If a peer-to-peer request is not scheduled within this 48-hour window, the provider will need to submit an appeal request.
New claim appeal status in NaviNet®
We made a small but important enhancement to the Claim Appeal statuses in NaviNet. Now when you submit an appeal the status will change to “In review” once your appeal is received. Although we can’t provide interim statuses on NaviNet, this change ensures you know your request is being processed. Once BCBSNE responds, the status will update to “Closed."
Below is a screenshot showing the new status button on the NaviNet appeal page.
Reminder: Emailing provider executives
Emails are handled in the order received; however, emails are not worked unless the below information is included.
Provider name, NPI and TIN
Claim numbers (if applicable)
Member name and ID
DOS
Expected outcome or reimbursement
Additionally, the appropriate steps MUST be followed BEFORE submitting an escalation request to this email box:
Step one: NaviNet
Please access NaviNet for all member, claim, authorization and appeal needs. If you do not have access to NaviNet please register by following the steps at Provider Academy.
Step two: Contact
If NaviNet is unsuccessful, please use the claims investigation tool located in NaviNet.
Step three: Escalating
For claim escalation needs that you are unable to resolve through NaviNet or Customer Service Claims (CSC) Investigation, you can email this email box and include why NaviNet or Claims Investigation was not successful. You should also include the inquiry number from Customer Service.
FOR FEE SCHEDULES:
All fee schedules are available in NaviNet and will no longer be available via CSC, email or inquiry.
If you are affiliated with a PHO, you must obtain the fee schedule from the PHO.
FOR TIMELY FILING:
Please submit your request via NaviNet using the Timely Filing form.
Please remember: Coordination of Benefits (COB) is not a member ID exception. Please complete the reconsideration form on NaviNet if another insurance was billed, recouped or denied the claim and you then submitted to BCBSNE.
Provider Executives no longer address COBs submitted incorrectly on a timely filing form.
The Nebraska Applied Behavior Analyst 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. For those applying for initial credentialing, previous board certification will still be required.
How to submit a claim
The preferred way to submit claims is through the Electronic Data Interchange (EDI). Claims can be submitted through your preferred clearinghouse as long as you are a BCBSNE-credentialed provider. If you do not already have a clearinghouse, BCBSNE offers free billing software and support to help you submit claims electronically.
If circumstances necessitate submitting claims on paper temporarily, please inform your Provider Executive. Their information can be found at NebraskaBlue.com/Provider-Contacts. This notification will enable us to prepare for the receipt of paper claims and help mitigate any potential downstream delays.
Coordination of Benefits: When a Blue Cross Blue Shield (BCBS) member also has Medicaid coverage
In most instances, Medicaid serves as the payer of last resort. When a patient is covered by both BCBS and Medicaid, BCBS is considered the primary payer. Claims should be submitted to BCBSNE (your local plan) first and will be processed up to the coverage limits. If there is a remaining balance, the claim should then be submitted to Medicaid as the secondary payer.
Breast cancer awareness – early detection saves lives
Except for some forms of skin cancer, breast cancer is the second most common cancer among American women regardless of race or ethnicity, but breast cancer does not just happen in women. Anyone born with breast tissue can get breast cancer. The American Cancer Society says when breast cancer is detected early, and in the localized state, the five-year relative survival rate is 99%.
Advances in breast cancer screening allow health care professionals to diagnose breast cancer earlier. Finding the cancer earlier makes it much more likely that the cancer can be cured. Even when breast cancer cannot be cured, many treatments exist to extend life.
Please educate your patients to know the signs and symptoms and to make an appointment as soon as they notice any changes, such as:
A breast lump or thickened area of skin that feels different from the surrounding tissue.
A nipple that looks flattened or turns inward.
Changes in the color of the breast skin.
Change in the size, shape or appearance of a breast.
Changes to the skin over the breast, such as skin that looks dimpled or looks like an orange peel.
Peeling, scaling, crusting or flaking of the skin on the breast.
Women who have dense breast tissue have a higher risk of breast cancer compared to women with less dense breast tissue and should have both a mammogram and breast ultrasound each year. Dense breast tissue is not abnormal or harmful. However, cancer can “hide” in dense tissue because they look the same on a mammogram image. On an ultrasound, diagnostic radiologists can see what they cannot see on the mammogram. Studies have shown that breast ultrasound and possibly magnetic resonance imaging can also help find some breast cancers that can’t be seen on mammograms.
BCBSNE will be hosting a virtual educational webinar to learn more about our Medicare Advantage (MA) product coming in house for 2025. Please be advised that the webinar presentation will be the same information that was provided in our in-person Lunch and Learns or Learn a Lattes.
Coming Soon: MA BCBSNE Provider Education Webinar on Friday, Nov. 15, from 2 to 3 p.m.
New ID number for current BCBSNE MA members Effective Jan. 1, 2025
BCBSNE is excited to inform you that all current BCBSNE Medicare Advantage members will receive a new member ID number, effective Jan. 1, 2025.
Key points to remember:
New ID cards: Members could begin to receive new ID cards in the mail by early October.
Prefix for new ID cards: To help identify which ID card is the new one for Jan. 1, 2025, the prefix will be different.
YMA4 will be the new prefix for the HMO product instead of YMAN.
Y2M4 will be the new prefix for the PPO product instead of Y2MN.
Effective date: These new ID numbers will not be valid until Jan. 1, 2025.
Usage: Please note that the new ID numbers should be used for services on or after Jan. 1, 2025.
If you receive a new ID number from a current BCBSNE Medicare Advantage member, please remember that it will only be effective for dates of service from Jan. 1, 2025, onwards.
Thank you for your attention to this important update!
Medicare Preauthorization Update for Medical Specialty Drugs
You recently received information on the Medicare Advantage Happening Now page regarding BCBSNE contracting with the Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime) to manage a new process for reviewing and approving certain specialty drugs effective Jan. 1, 2025, for Medicare Advantage members.
To help providers better prepare for this new program, we are offering online training. The Prime team of experts will walk you through the prior approval process. Understanding our new procedures will help ensure that your claims are processed promptly and accurately.
Join us for a 60-minute, web-based training session presented by Prime and become familiar with:
The policies and procedures for this new program.
What medical benefit drugs will require prior approval.
How to obtain access to the Prime website.
How to complete prior authorization requests using easy-to-use online tools from Prime.
Please take advantage of this learning opportunity!
It is recommended that you reserve your spot in one of these education sessions at least one week ahead of time. You will receive a registration confirmation email from Prime for the webinar session you select, including instructions for dialing in by phone should you need to do so.
Session 1
Session 2
Tuesday, Nov. 19, 2024
9 a.m. (Central Standard Time) bit.ly/BCBSNE1
Tuesday, Nov. 19, 2024
1 p.m. (Central Standard Time) bit.ly/BCBSNE2
You will only need to attend one of the above educational sessions.
Please note that you will be able to begin requesting prior authorizations beginning Dec. 19, 2024, for dates of service on or after Jan. 1, 2025, for Medicare members only. If you have questions, please reach out to your Provider Executive.
Medicare preauthorization update for musculoskeletal (MSK) and interventional pain management (IPM)
BCBSNE has expanded its partnership with Evolent (formerly National Imaging Associates, Inc) to include BCBSNE Medicare Advantage members for the MSK and IPM authorization programs that have existed for commercial members since 2015. Evolent’s MSK and IPM Solutions programs are intended to help providers effectively deliver quality patient care.
Evolent is an independent company providing MSK and IPM solution programs for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.
Effective Jan. 1, 2025, MSK and IPM services will require prior authorization through Evolent prior to being rendered in an inpatient or outpatient setting (MSK) or outpatient facility/office setting (IPM). Providers may begin contacting Evolent on Jan. 1, 2025, to seek prior authorization for procedures scheduled on or after Jan. 1, 2025. This prior authorization management program applies to your BCBSNE Medicare Advantage members.
Evolent uses clinical criteria based on nationally recognized guidelines to promote evidence-based practices.
The Evolent program will apply to all specialties for the following non-emergent inpatient and outpatient MSK surgeries:
Lumbar
Lumbar Microdiscectomy
Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy and Foraminotomy)
Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
Lumbar Artificial Disc Replacement – Single and Multiple Levels
Cervical
Cervical Anterior Decompression with Fusion – Single and Multiple Levels
Cervical Posterior Decompression with Fusion – Single and Multiple Levels
Cervical Posterior Decompression (without fusion)
Cervical Artificial Disc Replacement – Single and Multiple Levels
Cervical Anterior Decompression (without fusion)
The Evolent program will apply to all specialties for the following outpatient IPM procedures:
Via telephone at 1-800-424-4956. Staff is available Monday - Friday from 7 a.m. to 7 p.m. CST.
RadMD offers providers the ability to:
Request prior authorization and verify authorization status.
Upload required clinical documentation and view submitted files.
Access clinical guidelines, checklists and additional provider resources and tools.
Identify the dedicated Evolent Provider Solutions Manager to use as a direct point-of-contact for any issues or questions.
BCBSNE Medicare Advantage approvals issued before Jan. 1, 2025, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. For services/treatment that did not require an authorization prior to Jan. 1, 2025, an authorization may be required from Evolent for service/treatment dates on and after Jan. 1, 2025.
Any BCBSNE Medicare Advantage prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the service has met Evolent’s medical necessity criteria.
BCBSNE Medicare Advantage is proud to be your health care partner. If you frequently request MSK and/or IPM services and are new to this process, please register for a training session.
Meeting ID for Tuesday, Nov. 19, 2024 at 8 a.m. CST:
ID# 910 3096 1772 Meeting ID for Thursday, Nov. 21, 2024 at Noon CST:
ID# 979 5575 1234 Meeting ID for Tuesday, Dec. 10, 2024 at Noon CST:
ID# 941 1187 2952 Meeting ID for Thursday, Dec. 12, 2024 at 8 a.m. CST:
ID# 995 2090 7746
If you have questions, please contact BCBSNE Medicare Advantage Provider Services Department at 1-888-505-2022. If you have questions about Evolent MSK or IPM programs, please email RadMDSupport@Evolent.com or call 1-800-327-0641.
We look forward to offering you this program and hope it will enhance your experience with MSK and IPM authorizations.
Do you have a new team member who would like to be added to our email list?
They can sign up for Provider updates online in the same location as our Provider Updates newsletter on the Alerts and Updates page.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.
