Provider Update January 2024

Medical

Hot off the press – 2023 CAHPS results are in!

Every year health plan members are sent the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This survey assesses healthcare quality by asking patients to report on their experiences with care. CAHPS surveys ask about the patient’s experience with providers or care for specific health conditions, along with questions about their health plan and related programs.

We are happy to share the 2023 CAHPS survey results with you, please see tables below to review strengths and areas of opportunity.

^{* Improved YOY
- Above benchmark}

Providers play a key role in patient experiences and health outcomes. Understanding the way patients perceive care can help ensure your patients have a positive experience.

If you’d like to review the survey questions click for Commercial CAHPS and Medicare Advantage CAHPS. We look forward to our continued partnership in improving the overall healthcare experience for our shared members. 

2023 HEDIS^® Medical Record Review

Each year from February through May, BCBSNE performs medical record reviews to collect HEDIS measurement quality data for Medicare Advantage and Commercial members. BCBSNE uses Reveleer to collect data for commercial members and CIOX for Medicare Advantage members. Both Reveleer and CIOX look for clinical details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results and colorectal cancer screenings. Your clinic may be contacted by either Reveleer or CIOX requesting you provide the necessary records. We appreciate your assistance with these important reviews. Your cooperation helps us meet our quality goals as we seek to improve the overall health of our members – your patients. HEDIS medical record reviews reflect the quality of care quality-of-care patients receive that cannot be captured via the claims process. 

As a reminder, your contract as a participating provider contains language around the provision of providing requested records to BCBSNE or third-party vendors, at no charge, to capture the content of clinical encounters with our members. We don’t want to disrupt your office workflow more than necessary, so, the faster we obtain the requested records, the fewer follow-up contacts will be needed. Thank you in advance for your prompt response to our requests and for helping us successfully complete our HEDIS reporting. 

For more information on HEDIS visit NCQA.org. 

Developmental Testing Reimbursement Policy retired

The Developmental testing policy was retired on Dec. 1, 2023.  We will allow developmental and behavioral screening/testing CPT codes to be billed with a routine diagnosis.

Pegfilgrastim preferred biosimilar medication requirements effective Jan. 1, 2024

Effective Jan. 1, 2024, BCBSNE will update preferred Pegfilgrastim biosimilar criteria to policy X.179. Pegfilgrastim has multiple cost-effective options available. Patients who are currently approved for non-preferred medications will be allowed to continue use through their original authorization end date. After that time, a preferred Pegfilgrastim product will need to be utilized.

Patients who are new to therapy will also be required to use a preferred biosimilar agent prior to the use of non-preferred products. 

Preferred products will be Fulphila™ and Neulasta^®.

Non-preferred products will be Nyvepria™, Udenyca™, and Ziextenzo™.

Hyaluronic acid preferred medication requirements effective Jan. 1, 2024 

Effective Jan. 1, 2024, BCBSNE will update preferred hyaluronic acid criteria to policy I.196. Hyaluronic acid products have multiple cost-effective options available. Patients who are currently approved for non-preferred medications will be allowed to continue use through their original authorization end date. After that time, a preferred hyaluronic acid product will need to be utilized.

Patients who are new to therapy will also be required to use a preferred hyaluronic acid product prior to the use of non-preferred products.

Preferred products will be Synvisc^®, Synvisc One^®, and Orthovisc^®.

Non-preferred products will be all other hyaluronic acid products.

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Services

Effective Apr. 1, 2024, BCBSNE will apply a payment reduction when multiple eligible diagnostic imaging services are provided to the same patient on the same day by the same provider or different providers within the same group practice.

Aligning with the Centers for Medicare & Medicaid Services, MPPR on certain diagnostic imaging services applies to the professional component and technical component services. It applies to both professional component-only services, technical component-only services, professional component and technical component of global services, and to multiple units of the same technical component and professional component services.

Full payment is made for each professional component and technical component service with the highest payment under the Medicare Physician Fee Schedule for the procedures with a multiple surgery value of ‘4’ in the Medicare Fee Schedule database. Payment is made at 95 percent for subsequent professional component services. Payment is made at 50 percent for subsequent technical component services.

Professional claims with diagnostic imaging services should be submitted with a single date of service on each line. 

Online Medical Evaluation Services Policy effective April 1, 2024.

Online Medical Evaluation Services: Commonly referred to as E-Visits are non-face-to-face encounters originating from an established patient to a physician or other qualified health care professional for evaluation or management of a problem utilizing internet resources. BCBSNE will reimburse Online Evaluation and Management Services once every seven days by the same provider group. The services can include more than one provider within the same provider group attending the same patient. Online Medical Evaluation Services include all communication, prescription, and laboratory orders with permanent storage in the patient's medical record.

BCBSNE response to the new RSV codes

90678 and 90679 effective June 21, 2023
90380 and 90381 effective July 17, 2023  
96380 and 96381 effective Oct. 6, 2023

• Providers should ensure they are using the correct NDC number in addition to the correct dx code
• Prior authorization may be required - it is important to validate benefits and preauthorization requirements prior to service being rendered
• If our member elects to have this done in a pharmacy, prior authorization may be required outside FDA-approved and CDC supported use.
• BCBSNE allows for all children under the age of 2 to receive the RSV immunization vaccine regardless of diagnosis. Age 2 and older will deny as investigational
• BCBSNE allows for any age with gestation diagnosis codes for 32 through 36 weeks of gestation of pregnancy
• BCBSNE allows for age 60 and above with a preventive diagnosis. Medical diagnosis will apply member's cost share
• All other RSV vaccines will pay following the CDC recommendations

Dental

Faxed Claims 

BCBSNE does not accept faxed claims. Claims are accepted by electronic submission or by mail.

When submitting electronic claims to BCBSNE, please ensure you are using the correct payer ID. 
Dental: 00760 

NaviNet: Available to dentists

NaviNet is available to dentists to check claim status, eligibility and benefits, and fee schedules. The online portal is offered at no cost to our providers. It’s easy to use and gives you a dashboard to access helpful information for your Blue Cross and Blue Shield of Nebraska (BCBSNE) patients. If you have not tried NaviNet, we encourage you to do so.

Sign up here

ID cards and SOBs for BCBSNE members are also available in NaviNet. To view BCBSNE member ID cards and SOB summary choose the Eligibility and Benefits workflow and then enter the information for the member you wish to search. NOTE: The BCBSNE member ID does not need to be included to search.

Watch Happening Now as we continue to enhance NaviNet throughout 2024.

Medicare Advantage

Medicare Advantage: Medical and Pharmacy Policy Management 

Effective Jan. 1, 2024, BCBSNE will be responsible for managing Medical and Pharmacy Policies for Medicare Advantage members. BCBSNE will establish a Medicare Advantage Medical Policy committee which will review these policies.

What this means for providers: Providers will need to verify and review the Medical and Pharmacy Policies for Medicare Advantage as criteria may or may not have changed.

Learn more

Carelon code additions to prior authorization

Effective Jan. 1, 2024, Carelon will add the following new code to prior authorization. This is a new CPT code for 1/1/2024.

Medicare Advantage Claim Submissions

When submitting Host 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.

Host claims will return when the facility ZIP code is missing from Box 32
Medicare Advantage PPO paper claims (regardless of place of service) and Medicare Advantage PPO electronic claims (place of service 12) must be submitted with the service facility ZIP code in box 32.

Updates to Carelon Clinical Appropriateness Guidelines 

Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Clinical Appropriateness Guidelines (formerly AIM Specialty Health guidelines). As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updated Guidelines

Radiology

• Cardiac imaging / Imaging of the Heart
• Oncologic Imaging
• Brain Imaging 
• Head and Neck Imaging 
• Chest Imaging
• Abdomen-Pelvis Imaging

Musculoskeletal 

• Interventional Pain Management

Radiation Oncology 

• Radiation Therapy
      *  All other Radiation Oncology guidelines are reaffirmed without changes

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Security Corner

Telehealth

While telehealth provides many benefits for patient care, it can also expose healthcare delivery organizations (HDOs) to cyber risks. Help improve the security and privacy of telehealth services:

• Use HIPAA-compliant applications to provide telehealth services and limit the number of applications used.
• Use a private space and limit the number of people who take part in a telehealth session.
• Never use unapproved devices to access HDO applications, networks, or patient data.

For a complete list of telehealth privacy and security tips for providers, check out this resource from the National Institute for Standards and Technology (NIST).