Provider Update September 2023

Provider Updates: CSC Provider Inquiry and Remittance Advice starting Sept 1, 2023

We are excited to announce, because of our continued enhancements in NaviNet, we will begin to improve the way providers request remittances advices (RAs). RAs are and have been available on NaviNet for some time.

Effective Sept. 1, 2023, providers will no longer need to contact our Customer Service Center (CSC) for

• RAs – Remittance Advice is available on NaviNet 
• Checking claim status less than 30 days from submission  

In addition, inquiries should be sent via NaviNet Claim Investigation. The previous online inquiry process to Customer Service will only be available for Federal Employee Plan claim inquiries.

Please be advised our CSC team will redirect providers to NaviNet and will not be providing RAs nor will they address questions for claims statuses less than 30 days from submission.

In the event your RA is not available on NaviNet:

• Review our Happening Now to see if there is an already known issue 
• Reach out to your clearinghouse for a copy 
• Email ProviderExecs@NebraskaBlue.com with the payment number and payment amount 

Institutional Claims: Billing for private room stays 

As a reminder, value codes are required on all inpatient facility claims when submitting private room revenue codes. The value codes to be submitted when billing private room revenue codes according to the UB-04 Specifications Manual are: 

• “01” (semi-private room facility) must be accompanied by the semi-private room rate when facility offers semi-private rooms and the patient's stay is in a private room 
  o While a value code amount can be a variety of things (height, weight, age, dollars, days, etc. …) it is specifically treated as a dollar amount when submitted with value code 01
• “02” indicating “private room only” facility with $0.00 when the facility is private room only

Preauthorization for Genetic Testing

Preauthorization is required for many genetic tests. It is important to provide all of the information with the preauthorization request to ensure a smooth review process.

If the genetic counseling notes are not submitted with the preauthorization request, it may be delayed or denied. Genetic counseling documentation should be submitted by the ordering provider (not the laboratory). Please ensure this is done to avoid delays in preauthorization decisions.

Appointment Availability

To comply with regulatory requirements, BCBSNE has established appointment availability standards to ensure timely access to care for all members. In March 2023, a telephone survey was conducted with approximately 2,200 providers to evaluate compliance with the standards. Many providers did not demonstrate compliance with urgent, emergent or after-hours access standards. 

As a reminder, in-network providers agree to maintain appointment availability standards. To ensure compliance with each of the standards below, your office must be following at least one of the items noted in the Compliance column for each appointment type. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP). Please note that the next survey is scheduled for the fourth quarter of 2023. Please ensure you are in compliance with at least one of the following:

Appointment Type	Standard	Compliance
Urgent	Within 24 hours	Appointment can be scheduled within 24 hours Available for patient to walk in and receive care Triage is available with a nurse or other provider Patient is instructed to go to the urgent care, nearest ER or call 911
Emergent	Immediate	Available for immediate face-to-face medical attention Available for patient to walk in and receive care Triage is available with a nurse or other provider Patient is instructed to go to the urgent care, nearest ER or call 911
After-hours access	24/7 via phone	Live party is available after-hours Recorded message includes instructions on how to reach a live party Recorded message provides emergency instructions to go to the nearest ER or call 911

For a complete list of the appointment availability standards, please go to NebraskaBlue.com/ Providers/Credentialing.

Medicare Advantage: Boost your office by Joining Blue Cross Blue Shield CDI Alert Program

The process is simple and allows your office to stay up to date and get rewarded for their work. Please note, this program is only available to Medicare Advantage members. Please contact Monika Williams at Monika.Williams@NebraskaBlue.com or (402) 982-6017 if you have any questions.

Clinical Documentation Improvement (CDI) Alert Completion Tips 

How to Complete the CDI Alert 

1. Which response should be marked on the Alert? 
   • Mark Yes on the CDI Alert if the diagnosis or suggested diagnosis CDI opportunity is being addressed with the patient during the current face-to-face or audio and visual telehealth visit. 
   • Mark No if the diagnosis suggested diagnosis in a CDI opportunity does not exist (for example, diagnosis is resolved, or the patient never had it). 
   • Mark Not Addressed on the alert when either unsure if the diagnosis exists OR the diagnosis is valid and active, but the provider is not addressing it during the current the current visit for any reason (for example, patient is in for an acute illness, not enough time to get through the entire alert). 


2. What documentation is expected with each response? 
   • If YES is marked, there needs to be supporting documentation in the office visit note from the current face-to-face or audio and visual telehealth visit, showing the condition in question was addressed during the visit. 
   • If NO or Not Addressed is marked, no documentation is expected. 


3. What is considered sufficient documentation? 
   1. A condition is considered addressed if it includes the diagnosis and one or more of the following items. To make sure you’re following the guidelines for addressing a condition remember MEAT: 
      1. Monitoring by ordering test (For example, labs, X-rays, CT scan or echocardiograms)
      2. Evaluating as part of the physical exam (For example, monofilament exam for diabetic neuropathy or checking dorsalis pedis pulses for peripheral vascular disease) 
      3. Assessing the stability or progression of a disease (For example, documenting the condition is stable or improving) 
      4. Treating the condition (For example, providing a new prescription or instructing the patient to continue his or her current medication) Treating also includes referring patients to specialists, as related to their diagnosis (For example, to an ophthalmologist for exudative macular degeneration or to a psychiatrist for recurrent major depression) 
   
   Please note: A condition must be addressed, not only listed in the office visit note. Merely writing the diagnosis in the assessment or the problem list doesn’t satisfy the Centers for Medicare & Medicaid Services and ICD-10-CM Official Coding Guidelines for Coding and Reporting a condition as active. 


4. Additional information 
   1. If Yes is marked on the alert and no supporting documentation is found in the office visit note to show the condition was addressed during the visit, or if the documentation is incomplete or not specific enough to meet CMS guidelines for reporting a condition, a query will be issued to the provider requesting to add the missing or incomplete information. 
   2. A provider that receives a query is expected to amend his or her office visit note or add an addendum with the missing documentation that provides the complete and accurate representation of the diagnosis in the medical record. 
   3. CMS guidelines allow providers to change their documentation in the medical record up to 30 days from the date of the patient visit. Providers won’t be asked to make any changes to their documentation outside of the 30-day time frame. 
   4. The CDI Alert is not part of the permanent medical record. All documentation relative to the patient’s diagnosis, assessment, management, and referrals should be done in the office visit note. Providers are only expected to mark their responses on the alert, and sign and date it. 

_{ICD-10-CM diagnoses codes are ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding and Reporting are reviewed prior to the submission of claims.
Advantasure^™ is an independent company that provides health care technology solutions and services for Blue Cross and Blue Shield of Nebraska. Blue Cross and Blue Shield of Nebraska is a nonprofit corporation and independent licensee of the Blue Cross Blue Shield Association.}

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 Connect.NaviNet.net/Enroll to begin the registration process.

_{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska}

Preauthorization Requests

Preauthorization requests are reviewed in a timely manner, based on priority ordered by the provider. The timeline for review is from the receipt of the request to communicating the decision. The timeline is based on accreditation standards and regulatory requirements. Preauthorization requests include Pharmacy, Medical and Radiology.

Priority:

• Non-urgent: Includes up to 15 calendar days to communicate the review decision.
• Urgent: Includes requests ordered by the provider as urgent, meaning the 15-day timeline could seriously jeopardize the life or health of a patient or subject the patient to severe pain that cannot be adequately managed without the requested treatment. When the ordering provider indicates urgent, we communicate the review decision within 72 hours of receipt of the request.   
• Step-therapy: Except in the case of an urgent care request and upon receipt of complete, clinically relevant written documentation a review decision is provided within five calendar days. 

To ensure most efficient review of the request: 

• Use the online preauthorization portal through NaviNet^® for Medical and Radiology preauthorizations. The review turnaround time is quicker since it eliminates time spent setting up the request, and you may track the status of your request online. View the online preauthorization portal at NebraskaBlue.com/Providers/Preauthorization
• Always indicate the correct priority ordered by the provider, per their orders and/or medical records when you submit the preauthorization through the online tool or via a faxed request. 
• Always include medical records for clinical review by attaching a PDF document or adding a note in the online tool or faxing in the request. If not included, clinical staff will need to request medical records; this delays the clinical review until the records are received.  
• Always include the contact’s name, phone number and fax number in the online portal preauthorization request notes. This is helpful if additional medical records are needed to review your request. If there is no contact information, this will delay the request for medical records.

Always include the following on all faxed requests:

• The complete BCBSNE ID number, including the alpha prefix (this should match what is listed on the patient’s BCBSNE member ID card) 
• The complete patient’s name (this should match what is listed on the patient’s member ID card)
• Patient’s date of birth
• Patient’s address, city and state
• Ordering provider’s first and last name (NPI alone is not sufficient)   
• Ordering provider’s full address 
• Facility/rendering provider’s full name
• Facility/rendering provider’s address 
• Contact name, phone number and fax number who submits the request. 
• Procedure and diagnosis information

_{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska}

Remember to discuss fall risk, urinary incontinence and physical activity with Medicare patients

According to the National Committee for Quality Assurance (NCQA):

• Falls are the leading cause of death by injury in people 65 and older.
• Every year, one in three older adults fall.
• Urinary incontinence is significantly underreported and underdiagnosed.
• Any amount of physical activity reduces the risk of developing certain chronic conditions and increases quality of life.

Due to these serious health concerns, the Medicare Health Outcomes Survey (HOS) measures patient-reported outcomes for three HEDIS® Effectiveness of Care measures: 

• Fall Risk Management
• Management of Urinary Incontinence in Older Adults
• Physical Activity in Older Adults

The survey, which runs from August to November, asks randomly selected Medicare Advantage members questions about how providers talk about these important topics with them.

Read the HOS tip sheet to learn more, including what questions are asked and how you can address care opportunities with patients.

_{Sources:
Fall Risk Management - NCQA
Management of Urinary Incontinence in Older Adults - NCQA
Physical Activity in Older Adults - NCQA
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).}

Blood pressure coding can reduce HEDIS® medical record requests

The Controlling High Blood Pressure (CBP) HEDIS^® star measure assesses patients 18–85 years of age who had a diagnosis of hypertension reported on an outpatient claim and whose blood pressure was adequately controlled (<140/90 mm Hg) as of Dec. 31 of the measurement year.

Per HEDIS specifications, blood pressure CPT^® II codes can now establish patient compliance with the CBP measure. We will no longer need to review medical records to confirm blood pressure values when you add the CPT II codes to your patients’ claims billed with an office visit, including telehealth, telephone, e-visit or virtual visit.
Blood pressure readings can be captured during a telehealth, telephone, e-visit or virtual visit. Please note: 

• Patient-reported readings taken with a digital device are acceptable and should be documented in the medical record (MR).
• Providers do not need to see the reading on the digital device; the patient can verbally report the digital reading.

Read the CBP tip sheet to learn more about the measure and view a chart with blood pressure CPT II codes.

_{CPT^® is a registered trademark of the American Medical Association.}

Remind your eligible patients to get regular mammograms

One in eight women in the United States has a lifetime risk of getting breast cancer¹, and this lifetime risk is the second leading cause of cancer in women². Early detection is key to a better outcome for your patients, and you play an integral role by recommending regular screenings.

The Breast Cancer Screening (BCS) HEDIS^® star measure assesses female patients ages 50–74 who had a mammogram to screen for breast cancer in the past two years.

The National Committee for Quality Assurance now allows patients to be excluded from the measure due to advanced illness and frailty. They acknowledge that measured services most likely would not benefit patients who are in declining health.

Read the BCS tip sheet to learn more about this measure, including information to include in medical records, codes to include on patient claims to exclude for mastectomy and tips for talking with patients.

^{Sources:
1Understanding Breast Cancer Risk | Susan G. Komen®
2Breast Cancer Statistics | How Common Is Breast Cancer?}

Security Corner: AI Apps

Never share protected information with public Artificial Intelligence (AI) services, such as ChatGPT. These types of AI apps and websites use public input to learn, and later to respond to others.

Here’s an example scenario that could lead to a HIPAA violation:

A doctor enters a patient’s details into an AI chat app to have it draft a letter. In the future, if a third party asks the same chat app “what medical problem does [patient] have?”, it would be able to answer based on what the doctor provided.

Yikes!