Provider Update May 2024

Medical

Recent updates to policies

• Split-Year Claim Submission GP-X-093
• Hospital-Acquired Conditions (HAC) and Never Events RP-I-006
• Case Management/Care Plan Oversight Services RP-P-008
• Home Infusion Billing Guidelines RP-P-026
• Reconsideration of Unlisted Code Allowances RP-X-004
• Unlisted Procedure or Service RP-X-008

The following medical policies will have changes effective June 1, 2024. Please check back after June,1, 2024 to view these changes.

• I.212 Sympathetic Nerve Blocks
• I.195 Botox
• III.237 Treatment of Lymphedema and Lipedema
• IV.81 Radiology
• VIII.2 Contact Lens and/or Glasses

G0109 (Group Diabetic Education) will be added to our telehealth policy effective July 1, 2024

G0109 follows the same guidelines as other telehealth codes and requires modifier 95 with a place of service 02 or 10. In addition, the service must be billed by an approved telehealth provider.

Monaural hearing aids

Effective Aug. 1, 2024, monaural hearing aids must be billed with the appropriate HCPC code and an anatomical modifier of LT or RT. Claims for monaural hearing aids billed without the LT or RT modifier will be denied.

EAPG Providers

BCBSNE is making changes to the way our EAPG edits occur. Unforeseen impacts of having NCCI edits coupled with EAPG edits with NCCI built in caused impacts to the claims pricing.

This has been corrected and system edits have been completed. NCCI edits, in addition to the EAPG edits, are now appropriately pricing claims without the need for manual intervention. Claims are processing faster, and reconsiderations no longer need to be sent for payment adjustments.

Risk adjustment data validation audit

The Centers for Medicare and Medicaid Services (CMS) conducts an annual Risk Adjustment Data Validation (RADV) audit. The RADV audit verifies diagnosis codes submitted for payment, along with the corresponding medical records. BCBSNE will begin the process of retrieving medical records in June. Under the terms of your contract with us, health care professionals and facilities agree to submit medical records requested by BCBSNE in a timely manner at no cost to the patient or BCBSNE. Patients have consented to release medical records to us. An additional release is not required for this audit. All information resulting from the review is confidential. 

Ensuring timely access to care: A critical imperative for health care providers

In the complex landscape of health care delivery, timely access to care stands as a cornerstone of patient safety, satisfaction and regulatory compliance. Recent findings from BCBSNE’s survey conducted by Press Ganey on provider appointment availability have unveiled a concerning reality – many providers are struggling to meet emergent, urgent and after-hours care standards, with an average score of only 54%.

As we navigate these challenges, it becomes crucial to underscore the profound importance of meeting these standards to safeguard patient well-being and enhance health care outcomes.

Patient Satisfaction: Meeting access standards positively influences patient satisfaction scores, which are pivotal for the reputation and success of health care organizations. Members rely on timely access to care to address their health concerns promptly, and satisfaction with this aspect of care significantly impacts their overall perception of the health care experience. By prioritizing accessibility, providers can enhance patient trust, loyalty and engagement, thereby fostering a thriving health care ecosystem.

Legal and Regulatory Compliance: Access and Availability standards are not just best practices; they are mandated by regulatory bodies such as CMS and URAC. It is incumbent upon providers to grasp the vital importance of governing their practice and take proactive measures to ensure compliance, thereby mitigating risks and upholding ethical standards.

Provider Responsibility: At the heart of health care lies a sacred trust between providers and patients. Providers have a professional obligation to prioritize patient needs and deliver care in a manner that is timely, compassionate and patient-centered. Embracing this responsibility entails a commitment to meeting access standards and continuously improving the quality of care provided.

Impact on Continuity of Care: Failure to meet access standards can disrupt continuity of care, leading to fragmented health care experiences, unnecessary hospital admissions and delayed treatment interventions. By adhering to access standards, providers can promote continuity of care, optimize health outcomes and minimize the burden on health care systems.

The imperative to ensure timely access to care transcends mere compliance; it is a moral and professional obligation that corroborates the essence of health care delivery. By prioritizing patient safety, satisfaction and regulatory compliance, providers can cultivate a culture of excellence, compassion and accountability, ultimately advancing the health and well-being of members and communities alike.

As we strive for progress, let us rally behind the goal of achieving 95% compliance in the next quarter – reaffirming our commitment to delivering equitable, accessible and patient-centered care for all.

Dental

Orthodontic claims for University of Nebraska members

On Jan. 1, 2024, University of Nebraska employees and their dependents joined BCBSNE for their medical and/or dental coverage. These members have the prefix UNE, or, if their only coverage is dental, YZL. To ensure timely processing of your claims, please confirm you are submitting to the appropriate carrier for the date of service.

Please see policy number DP-X-004 if you need guidance in submitting orthodontic claims.

Medicare Advantage

Medicare Advantage Access Standards

BCBSNE establishes provider access standards in accordance with CMS regulations for BCBSNE Medicare Advantage members. The following standards apply to BCBSNE Medicare Advantage Primary Care and Behavioral Health in-network providers for BCBSNE Medicare Advantage. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP).

CMS requires the hours of operation of practitioners are convenient for and do not discriminate against members. Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours service, or recorded message directing members to a physician for after-hours care instruction. Recorded messages instructing members to obtain treatment via an emergency room for conditions that are not life threatening is not acceptable.

Provider Type	Appointment Type
Primary Care Provider General Practice Family Practice   Internal Medicine Pediatric Medicine Obstetrics and Gynecology practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
Behavioral Health Provider Psychology Psychiatry  Mental Health and Substance Abuse practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.

Security Corner

Security Fatigue

All of the security policies in the world cannot protect sensitive information if your staff is overburdened by complex, manual security requirements.

Combat “Security Fatigue” amongst your workforce, while allowing them to maintain secure behavior:

1. Limit the number of security decisions that staff need to make on their own.
2. Make it simple for staff to choose the right security option(s).
3. Design policies and systems for consistent security decision-making whenever possible.

In the end, the goal should be to make it easier for your staff to be secure than not secure. For more information, visit NIST.gov and search for keyword Security Fatigue.