To become a contracting Blue Cross and Blue Shield of Nebraska (BCBSNE) provider, all applicants must complete the credentialing process and have a signed agreement on file prior to being accepted into the network. New practitioners wishing to join BCBSNE can complete the CAQH application at CAQH.org. For more information regarding credentialing requirements and/or to request a provider agreement, please visit NebraskaBlue.com/Providers/Credentialing.
Effective Nov. 6, 2022, BCBSNE requires all providers who are not sole proprietors to have a Type 2 NPI number. This is required to align with Blue Cross Blue Shield Association standards.
If you do not currently have a Type 2 NPI number on file, you can apply at nppes.cms.hhs.gov/. Providers without a Type 2 NPI number on file will be subject to contract termination. Please ensure you are keeping all your data current in NPPES. The Blue Cross Blue Shield Association verifies all BCBSNE provider data against NPPES to confirm that taxonomy and NPI information are valid and accurate.
Provider Directory: Make Sure that Your Information is Correct
The Consolidated Appropriations Act (CAA), effective Jan. 1, 2022, requires that online provider directory information be reviewed and updated, if needed, at least every 90 days.
All providers (including dentists) can now review directory information in NaviNet. Directory information for your office can be located under Practice Documents.
For PHO groups handling their own credentialing processes, we will be requesting submission of a full roster every 90 days.
Please take a few minutes to review your online provider directory information to help ensure BCBSNE members can locate your most current information.
If changes are needed, please take the time to update your information by submitting updates and corrections via one of our provider forms on NebraskaBlue.com/Providers/Find-a-Form.
NaviNet®: New enhancements are live!
BCBSNE is excited to announce new enhancements available through NaviNet:
View both the front and back of BCBSNE member ID cards through the Eligibility and Benefits workflow.
View the schedule of benefits summary for BCBSNE members. After completing an Eligibility and Benefits search, you will have the option to view the BCBSNE member’s schedule of benefits summary.
Access additional details on claims that encounter issues before adjudication via Claim Status Search.
For more information on all transactions available on NaviNet for BCBSNE, please visit the NaviNet Help Center.
NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska.
CLIA tests and QW modifier
In the June 2022 provider email blast, providers were notified that the QW modifier would be required on CLIA-waived lab tests effective Sept. 1, 2022.
In response to your feedback, BCBSNE reversed the decision to require the QW modifier on CLIA-waived lab tests. Our claim system has been updated and CLIA-waived lab tests missing the QW modifier will no longer deny.
Please do not resubmit previously denied claims. A report has been run for the period of Sept. 1 through Oct. 21, 2022, with adjustments taking place as of the publication of this newsletter.
Medical Record Retrieval Coordinator for Affordable Care Act Programs
Inovalon® is authorized to retrieve medical records for out-of-area Blue members or from providers in other Plans’ service areas to support Healthcare Effectiveness Data and Information (HEDIS), Risk Adjustment, and government-required programs related to the Affordable Care Act on BCBSNE’s behalf.
Inovalon is an experienced health care analytics company and best-in-class supplier. The vendor will provide an efficient centralized process to coordinate medical record requests from Blue Cross and Blue Shield companies across the country and help reduce multiple requests for patient data.
Effective medical record retrieval services play a fundamental role in driving optimal quality reporting outcomes and ensuring appropriate risk scores.
Blue Cross Blue Shield Plans will initiate their annual projects on:
HRADV start date: June 2022 HRADV end date: December 2022
MRA start date: May 2022 MRA end date: January 2023
CRA / RADV start date: January 2022 CRA/RADV end date: December 2022
HEDIS start date: January 2023 HEDIS end date: May 2023
As outlined in your contract, you are required to respond to requests in support of Risk Adjustment, HEDIS, and other government required activities within the requested timeframe. This includes requests from Inovalon on our behalf. BCBSNE is working diligently to make this process as simple as possible.
For your convenience medical records may be submitted to Inovalon in the following ways:
Phone: 844-682-9764 (for questions on delivery options/methods)
Inovalon is an independent contractor that provides data storage and analytics services on behalf of Blue Cross and Blue Shield of Nebraska.
HIPAA/Privacy
Inovalon is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI) obtained from medical records, in accordance with HIPAA regulations. Please note that patient-authorized information releases are not required in order for you to comply with these requests for medical records.
Providers are permitted to disclose PHI to health plans without authorization from the patient when both the provider and health plan had a relationship with the patient and the information relates to the relationship [45 CFR 164.506(c)(4)]. For more information regarding privacy rule language, please visit hhs.gov/ocr/privacy.
If you have any questions, please do not hesitate to contact your Provider Executive.
Check replacement forms
For a check replacement form to be processed, the signature must be secure, meaning that the signature is not able to be modified.
A signature is considered secure when the form is submitted via one of these two options:
Print the completed form, sign, and fax to 402-398-3809
Complete the online fillable form and submit via a secure signature feature such as Adobe DocuSign
Check replacement forms that are not submitted via one of the above methods will be returned.
Human Papillomavirus (HPV) Vaccine
Since 2017, Gardasil® 9 has been the only HPV vaccine available in the U.S.
The only code that should be billed for the HPV vaccine is 90651: Human Papillomavirus Vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use.
BCBSNE does not allow reimbursement for quadrivalent (90649) and bivalent (90650).
Effective Jan. 1, 2023, BCBSNE will add preferred Pegfilgrastim biosimilar criteria to policy X.179. Pegfilgrastim has multiple cost-effective biosimilar alternatives 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 that 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 Udenyca™.
Non-preferred products will be Neulasta®, Neulasta OnPro®, Nyvepria™ and Ziextenzo™.
Individual Open Enrollment has Started: Changes to plan offerings
The open enrollment period for individual ACA marketplace plans began on Nov. 1, 2022, for plans effective Jan. 1, 2023. If you have patients with individual ACA plans, the offerings in Nebraska are changing for 2023. BCBSNE will be offering a variety of plans, under the product name Nebraska HeartlandBlue. In addition, Bright Health has made the decision to leave the ACA marketplace which means members on their individual ACA plans will terminate as of the end of the year. Bright Health has sent their members letters notifying them of their decision to discontinue their plans. The Nebraska Department of Insurance will evaluate plans available in the market and will make a recommendation to the Centers for Medicare and Medicaid Services on where to move those members. If you have patients with questions about their coverage options, you can direct them to our licensed sales agents at 844-665-1121.
Nebraska HeartlandBlue
In the September 2022 Update, we announced that BCBSNE will be entering the ACA market with our new Nebraska HeartlandBlue plans.
These plans can be identified by their alpha prefix YST or YNQ.
A sample ID card is provided below. For more information on Nebraska HeartlandBlue, please see the September 2022 issue of the Update newsletter.
Reminder: Ordering providers must submit prior authorization requests
When prior authorization is required, the ordering provider or the rendering provider (lab, facility, DME provider, etc.) may submit the prior auth request.
The request must include the ordering provider’s documentation for the prior auth service. For example, XYZ Genetics Laboratory submits the prior auth request and includes the ordering provider’s medical necessity documentation/order for the service.
Another example, ABC Hospital may submit a prior auth for an MRI brain and include the ordering provider’s medical necessity documentation/order for the service.
If the prior auth request is for an FEP member and the request is from an out-of-state provider and will be billed by the out of state provider, that provider must submit the request to that state’s carrier. For example, if a Nebraska FEP member has lab services that will be billed out of California, the prior auth needs to be done in California.
BCBSNE does not allow retro-authorizations; ordering providers should ensure medical policy is reviewed to determine if prior authorization is required.
To search for applicable medical policies for any of your office’s BCBS members, please use the Medical Policy and Pre-Certification Router tool. Entering the member’s ID card prefix will direct you to the Plan’s medical policy page.
Amazon Pharmacy
Effective Jan. 1, 2023, Amazon Pharmacy will be the exclusive home-delivery pharmacy for BCBSNE members. Members can select home-delivery through Amazon Pharmacy for their long-term maintenance medications. Amazon Pharmacy automatically leverages the lowest price for members and offers enhanced member engagement through a simplified shopping experience. For Amazon Prime member, medications will be shipped for free in two days and five days for non-Amazon Prime members.
Amazon Pharmacy does not dispense controlled substances. Amazon Pharmacy is an independent company that provides pharmacy home delivery services for Blue Cross and Blue Shield of Nebraska.
Medicare Advantage: Prepare your patients for their annual wellness exams
The new year will bring new and existing Medicare Advantage members to your medical practice for their annual wellness visits. These visits play an important role in helping your patients maintain or improve their health through disease prevention and detection. They are available at no extra cost to members and members will receive a $50 gift card for completing a visit.
Medicare Advantage providers will also receive $50 for closing the visit care gap. The types of visits that will close this gap include:
Physical exam codes: 99381 to 99387 and 99391 to 99397
Wellness exam codes: G0438, G0439
Welcome to Medicare exam code: G0402
You can also offer to conduct an annual wellness visit via telehealth depending on your office’s capabilities.
CPT Copyright 2017–2022 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Medicare Advantage: Transitions of Care HEDIS® measure focuses on medication management & care coordination for Medicare beneficiaries
According to the American Journal of Managed Care, the ineffective transferring of a patient from one care setting (e.g., a hospital, nursing facility, primary care physician, long-term care, home health care, specialist care) to another often leads to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, medication nonadherence and, most importantly, unnecessary readmissions.
The Transitions of Care (TRC) HEDIS® measure for star ratings focuses on the percentage of members who had an acute or non-acute inpatient discharge during the measurement year and who had each of the following:
Notification of inpatient admission
Receipt of discharge information
Patient engagement after inpatient discharge
Medication reconciliation post-discharge
Documentation of all four components must be in any outpatient record, as well as accessible by the PCP or ongoing care provider.
We encourage you to establish an office practice that explains to patients why it’s critical they inform your office about their hospital admissions and discharges. Let them know this is important because it can improve their care coordination and maintain their safety.
Read the tip sheet to learn more about the measure, including exclusions, best practices, and documentation requirements.
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
New HEDIS® measure: Follow-up after an emergency department visit is important patient care
Many patients discharged from the emergency department (ED) require urgent follow-up care with their providers due to their high-risk chronic conditions. Often, an ED discharge is based on the presumption of continued care.
The Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) is a new HEDIS® measure for star ratings. It focuses on the percentage of members aged 18 and older who have multiple high-risk chronic conditions and who had a follow-up visit within seven days of an emergency department visit.
There are many ways to conduct a follow-up visit, including outpatient, telephone, Transitional Care Management, case management, complex care management, outpatient or telehealth behavioral health, intensive outpatient encounter or partial hospitalization, community mental health center, electroconvulsive therapy, telehealth, observation, e-visit or virtual check-in.
Read the tip sheet to learn more about this measure, including information about eligible chronic conditions, exclusions, best practices, documentation requirements and more.
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Revised HEDIS® measure focuses on helping prevent unnecessary hospital readmission
According to the Centers for Medicare & Medicaid Services, readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse patient outcomes and higher costs.
The Plan All-Cause Readmissions (PCR) HEDIS® measure assesses the percentage of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. This is a returning measure to the program for 2022.
Coordinating care from the hospital to home and ensuring a follow-up visit with the primary care physician can help your patients avoid readmission.
Read the tip sheet to learn more about this measure, including information about exclusions, best practices and tips for success while talking with patients.
Healthcare Effectiveness Data Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Not sure where to start to make sure your practice’s Protected Health Information (PHI) stays protected? The Federal Trade Commission says a good first step is to focus on these basics:
Control who logs on to your network and uses your computers and other devices.
Use up-to-date security software on all your devices.
Encrypt sensitive data, at rest and in transit.
Conduct regular backups of data.
Have formal policies for safely disposing of files and old devices.
Train everyone who uses your computers, devices, and network about cybersecurity.
As a contracting Blue Cross and Blue Shield of Nebraska health care provider, this newsletter serves as an amendment to your agreement and affects your contractual relationship with us. You are encouraged to file every issue of Update within your BCBSNE Policies and Procedures Manual and reference it often.
NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield of Association.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
