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Provider Update July 2025

Welcome to our new Update Newsletter format where information for our medical, dental and Medicare Advantage products is included in one publication.

General Information

NaviNet®: Change to submit appeals, timely filing requests and reconsiderations is now live

As we announced in our June issue of the Provider Bulletin, a change was implemented to streamline the process for submitting appeals, timely filing requests and reconsiderations via NaviNet. Previously, the system required selecting a “type” (Appeal, Recon or Timely Filing). This has now been updated to select a “reason” from the dropdown menu.

New submission process
To submit a request:

  1. Go to your claim status details.
  2. Click on the Appeal button and select the reason for your request.
  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.

Provider notice: High-dollar claim threshold update

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.

As we announced in June on Happening Now, effective Aug. 1, 2025, the high dollar claim threshold will be adjusted from $100,000 to $75,000.

What’s changing?

  • New threshold: Claims equal to or exceeding $75,000 will now be subject to high dollar review. The previous threshold was $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.

Transition to electronic remittance advices and payments

Blue Cross and Blue Shield of Nebraska (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.

BCBSNE partnered with Cotiviti for enhanced payment accuracy 
In our September 2024 Provider Update, we proudly reaffirmed our commitment to achieving greater payment accuracy. Building on this promise, we announced our partnership with Cotiviti in April 2025. 
 
In May 2025, Cotiviti began conducting periodic post-payment reviews of paid medical claims, including Clinical Claim Validation (CCV). This collaboration enhances our efforts to ensure accuracy and efficiency, leveraging the expertise of our new vendor.  
  
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, which is typically 12 months. Currently, the reviews include Local, Host and Federal Employment Program claims. 
   
About Cotiviti 
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 with 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.
Sign up for NaviNet

Registration is free; all you need is a Federal Tax ID. All participating BCBSNE health care and dental providers can enroll for access. 
 
If your office is already using NaviNet, please contact your Security Officer to create a NaviNet account for you. If you do not have a NaviNet account, please visit Register.NaviNet.net to begin the registration process. 

Medical: Commercial and FEP

Upcoming change in medical policy III.219: Preauthorization requirement for biventricular pacemaker with and without ICD
In May, we announced that effective Aug. 1, 2025, medical policy III.219 will undergo significant changes regarding biventricular pacemakers with and without ICDs. Procedure code 33249 will now require preauthorization, whether the ICD is dual or single chamber.

This update aims to ensure that all patients receive appropriate and necessary care while maintaining the integrity of the health care system. Providers are encouraged to familiarize themselves with the new preauthorization requirements to avoid any disruptions in patient care.

For more information and detailed guidelines, please refer to the updated medical policy.
Expansion of prior authorization (PA) requirement for specialty drugs 
In our June Provider Bulletin and on Happening Now, we previously announced that the management of certain specialty drugs under the medical benefit will be expanded to include our Commercial members. Beginning Sept. 30, 2025, providers should begin contacting Prime Therapeutics to obtain PA for the in-scope drugs for our Commercial members with dates of service on or after Sept. 30, 2025.  
  
PA 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 requests and clinical guideline information please visit GatewayPA.com. 
 
For urgent and expedited requests please call 800-424-1709. 
 
For answers to frequently asked questions please see Medical Pharmacy Prior Authorization Program in our Provider Academy.

Medicare Advantage

Improving Medicare Advantage (MA) AWV-CPE completion rates

Current challenge
Current completion rates for MA annual wellness visits (AWVs) and comprehensive physical exams (CPEs) are currently below desired expectations. This shortfall impacts not only patient health outcomes but also your clinic's performance metrics.

Understanding AWVs and CPEs

  • Annual wellness visit (AWV): A preventive service covered by BCBSNE, focusing on creating or updating a personalized prevention plan based on the patient's current health and risk factors.
  • Comprehensive physical exam (CPE): This service, also covered by BCBSNE, is a thorough evaluation of a patient's physical health, often encompassing assessments not included in the AWV.

Benefits for patients

  • Preventive focus: AWVs help in early detection of potential health issues, allowing for timely interventions.
  • Cost-free access: Medicare covers AWVs at no cost to patients, eliminating financial barriers.
  • Personalized care plans: Patients receive tailored health advice and preventive care recommendations based on their health status and risk factors.

Benefits for providers

  • Quality measure reporting: AWVs offer an opportunity to address care gaps and report quality measures important in pay-for-performance systems.
  • Strengthened patient relationships: Regular wellness visits foster stronger patient-provider relationships, enhancing patient engagement and satisfaction.

Conclusion
Enhancing the completion rates of AWVs and CPEs is crucial for improving patient health outcomes and optimizing clinic performance. By completing these encounters, we can ensure that our patients receive comprehensive preventive care, while also meeting clinic's operational and financial goals.

MA CMS RADV changes

BCBSNE is committed to transparency and keeping our providers informed. We are reaching out to notify you of significant changes and updates to the CMS RADV auditing process. Your support in providing medical records will be crucial as we navigate these changes.

Key update:
On May 21, 2025, CMS announced a dramatic expansion of its RADV audit program that will affect all MA plans. This represents the most significant change to RADV auditing in the program's history.

What's changed:

  • Annual audits: CMS will now audit all eligible MA contracts annually (previously ~60 contracts per year).
  • Increased sample sizes: Audit sample sizes will increase from 35 to up to 200 member records per contract.
  • Expedited completion: CMS is expediting the completion of all audits for Payment Years 2018-2024 by early 2026.
  • Expanded workforce: The agency is expanding its medical coder workforce from 40 to 2,000 coders by September 2025.
  • Enhanced technology: Enhanced AI technology will be deployed to identify potentially unsupported diagnoses.

Although these audits are on the MA Organization, upon request, BCBSNE will need your support in providing medical records.

Thank you for your continued partnership and cooperation.

Important update for providers: Readmissions

Beginning Aug. 1, 2025, BCBSNE MA claims for readmissions will follow the CMS guidelines denying the second readmission.

Please view the MA Readmission Quality Program procedure for more information.

Quality and Risk

Immunizations: Documentation essentials for providers

Immunizations are a cornerstone of preventive care, helping protect individuals and communities from serious illnesses. From childhood vaccines to adult boosters like influenza and pneumococcal vaccines, staying up to date reduces morbidity, hospitalizations and health care costs. For providers participating in risk adjustment programs, clear and accurate documentation of immunizations — and any relevant conditions affecting immunization status — is essential to ensure accurate capture of a patient’s health status.

Key documentation elements for risk adjustment1, 2, 3

  1. Accurate diagnosis capture:
    • Clearly document any chronic conditions that may impact immunization decisions (e.g., immunosuppression, chronic kidney disease).
    • Link immunization refusal or contraindication to a relevant diagnosis when applicable.

  2. Z-codes for immunizations
    • Use appropriate ICD-10 Z-codes to reflect immunization services and related patient conditions:
      • Z23 – Encounter for immunization
      • Z28.01 – Immunization not carried out due to acute illness
      • Z28.03 – Immunization not carried out due to immune compromised state
      • Z28.82 – Immunization not carried out due to caregiver refusal

  3. Conditions that may impact HCCs
    • Immunocompromised status (e.g., HIV, transplant recipients, chemotherapy) can map to HCCs.
    • Chronic conditions such as diabetes, COPD or ESRD influence vaccine prioritization and should be documented annually.

  4. Problem list review
    • Ensure problem lists are updated and reflect active, monitored and treated conditions relevant to immunization decisions.

Documentation tips for immunizations1, 2, 3

The following is required documentation for risk adjustment:

  • Be specific: Vague documentation like “needs vaccines” does not support coding. Instead, specify which vaccine and the reason.
  • Use MEAT criteria: Each condition should be Monitored, Evaluated, Assessed or Treated during the visit.
  • Annual review: Review and document chronic conditions annually, even if stable, to support accurate HCC capture.
  • Refusals matter: Document patient refusals or deferrals with a reason and corresponding Z-code.
  • Consistency across records: Ensure documentation aligns in progress notes, problem lists and billing.

Accurate immunization documentation not only improves patient care but also ensures proper risk adjustment, impacting quality scores and reimbursement. By following these best practices, providers can enhance documentation integrity while ensuring patients receive the care they need.

Providers are responsible for documenting and coding all conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management.
 
For any questions or requests for additional documentation and coding education, please contact us at RiskAdjustment@NebraskaBlue.com.

References: 
1The Centers for Disease Control and Prevention (CDC). (2024, August). Introduction to Immunization Best Practice. Vaccines & Immunizations. https://www.cdc.gov/vaccines/hcp/imz-best-practices/introduction.html
2Healthcare Professionals. (2019). https://www.cdc.gov/vaccines/hcp/index.html
3CDC. (2024). Site Index. Vaccines & Immunizations. https://www.cdc.gov/vaccines/site.html

Understanding HEDIS® immunization measures: A 2025 overview

The Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA), is one of the most widely used tools in the United States for measuring health care performance. Among its many focus areas, immunization measures play a critical role in assessing preventive care across populations.

What are HEDIS immunization measures?
HEDIS immunization measures evaluate whether individuals — particularly children, adolescents and adults — receive recommended vaccines according to CDC guidelines. These measures are essential for:

  • Preventing vaccine-preventable diseases
  • Promoting public health
  • Ensuring timely and equitable access to care

Key immunization measures in 2025
For the measurement year 2025, HEDIS includes several immunization-related measures, categorized by age group:

  1. Childhood immunization status (CIS)
    This measure assesses the percentage of children who receive a full series of recommended vaccines by their second birthday. The series includes:
    1. DTaP
    2. IPV
    3. MMR
    4. HiB
    5. Hepatitis B
    6. Varicella
    7. Pneumococcal conjugate
    8. Hepatitis A
    9. Rotavirus
    10. Influenza

  2. Immunizations for adolescents (IMA)
    This measure evaluates whether adolescents aged 13 received:
    1. One dose of meningococcal vaccine
    2. One Tdap or Td vaccine
    3. Two or three doses of the HPV vaccine (depending on age at initiation)

  3. Adult immunization status (AIS)
    This newer measure assesses whether adults aged 19 and older received:
    1. Influenza vaccine
    2. Tdap or Td booster
    3. Zoster vaccine (for those 50+)
    4. Pneumococcal vaccine (for those 65+)

2025 updates and trends
According to NCQA, the 2025 HEDIS updates reflect a continued shift toward electronic clinical data systems (ECDS) reporting, which allows for more comprehensive and accurate data collection. This transition supports better tracking of immunization rates and helps identify gaps in care.

Additionally, NCQA has made refinements to measure specifications to align with evolving CDC guidelines and improve clarity for health plans and providers.

How to improve immunization measures
Providers can capitalize on opportunities to influence a patient's immunization decision. One study in Ohio identified key influences:

Top factors influencing immunization decisions:

  • Doctor's recommendation (80.6%)
  • Knowing why a vaccine is needed (78.2%)
  • Knowing which vaccines are needed (75.5%)
  • Cost (54.2%)
  • Concern about getting sick from the vaccine (54.0%)

Disparities: Significant differences in factors influencing immunization decisions based on ethnicity and education level.

Chronic diseases: Less than half of participants with diabetes, heart disease or asthma were aware that certain immunizations could reduce complications from their diseases.

The study suggests that targeted education programs focusing on the benefits and indications for vaccines could improve vaccination rates, especially for patients with chronic diseases.

Why these measures matter
Immunization measures are not just about compliance, they are about saving lives and reducing health disparities. By tracking and improving vaccination rates, health plans and providers can:

  • Reduce the incidence of preventable diseases
  • Improve population health outcomes
  • Meet quality benchmarks tied to reimbursement and accreditation

References
HEDIS MY 2025: What’s New, What’s Changed, What’s Retired
HEDIS Measures and Technical Resources - NCQA
Sevin AM, Romeo C, Gagne B, Brown NV, Rodis JL. Factors influencing adults' immunization practices: a pilot survey study of a diverse, urban community in central Ohio. BMC Public Health. 2016 May 23;16:424. doi: 10.1186/s12889-016-3107-9. PMID: 27216805; PMCID: PMC4877755.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Value-based Care

What is value-based care?

Value-based care (VBC) is a care delivery model that emphasizes quality and efficiency, with the goal of better health outcomes and experiences for members and providers. BCBSNE partners locally with primary care physicians to help coordinate care, keep quality high and lower the growth of health care costs.

What are the key principles of value-based care?

  • Patient-centered: Care is designed around an individual’s needs, goals and preferences.
  • Quality over quantity: Providers are rewarded for improving patient health outcomes, not for the number of tests or procedures performed.
  • Coordinated care: Emphasizes collaboration among providers to ensure seamless, holistic care.
  • Cost efficiency: Encourages the reduction of unnecessary services and promotes preventive care to lower overall health care costs.
  • Accountability: Providers are held responsible for both the cost and quality of care delivered to their attributed patient population.*

*Dependent upon the type of agreement between BCBSNE and the contracting entity.

What value-based care agreements are available at BCBSNE?

BCBSNE offers VBC agreements to:

  • Accountable care organizations (ACO):
    • Three-year term
    • Shared saving/risk models
  • Patient-centered medical homes (PCMH):
    • One-year term
    • Pay-for-quality model
  • Independent clinics:
    • One-year term
    • MA population
    • Pay-for-quality model

Eligibility criteria exist in each agreement offering and must be met to be eligible for participation.

Are all providers eligible to participate in BCBSNE’s value-based care agreements?

Currently, the following provider specialties are eligible to receive attribution in BCBSNE’s base value-based care agreements:

  • Advanced Registered Nurse Practitioner*
  • Family Practice
  • General Practice
  • Geriatric Medicine**
  • Gynecology
  • Internal Medicine
  • Nurse Practitioner*
  • Obstetrics-Gynecology
  • Pediatrics
  • Physician Assistant*
  • Preventive Medicine

*These providers can only be considered as eligible primary care physicians if practicing under one of the other provider specialties listed.
**Specific to Medicare Advantage Attribution

For further inquiries regarding our VBC opportunities, please contact VBPQuestions@NebraskaBlue.com.

Security Corner

Business vendors

Your business vendors, or third-party contractors, may have access to sensitive information as part of their job duties. Make sure those vendors are securing their own computers and networks too. You can:

  • Put it in writing. Include provisions for vendor security in your vendor contracts.
  • Verify compliance. Establish processes so you can confirm that vendors follow your rules.

This newsletter serves as an amendment to your agreement as a contracting Blue Cross and Blue Shield of Nebraska health care provider and affects your contractual relationship with us.
NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska.
Cotiviti is an independent company providing post pay claims data mining and DRG audit services for Blue Cross and Blue Shield of Nebraska.
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. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and mail service company.
HEDIS, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance (NCQA).
Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross Blue Shield Association. The Blue Cross Blue Shield Association licenses Blue Cross and Blue Shield of Nebraska to offer certain products and services under the Blue Cross® and Blue Shield® brand names within the state of Nebraska.

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