Provider Update November 2023

State Mandate for Telehealth Reimbursements

As mandated by the Nebraska Department of Insurance, effective Sept. 1, 2023, all credentialed providers who are eligible to provide telehealth services (see policy GP-X-016, Telehealth) will be reimbursed at 100% of the in-person allowed amount.

Behavioral Health Providers: LB487 effective Sept. 1, 2021, mandated that in-network telehealth behavioral health services to be covered at 100% of the in-person allowable amounts. Behavioral health services provided via telehealth will continue to be reimbursed at 100% of the in-person allowable amounts.

Providers exclusively delivering telehealth services must live in the state of Nebraska, be a member of a credentialed Nebraska-based PHO or employed by a licensed or credentialed facility in Nebraska. Providers will also still need to meet the credentialing criteria that is available at Credentialing Information for Providers.

Jan. 1, 2024, changes to our Readmission Policy and Genetic Testing policy

To align with the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP), facilities are encouraged to improve communication and care coordination for patients and caregivers in discharge planning to reduce avoidable readmissions. Patients are more likely to have better outcomes, functional ability, survivability and quality of life.

Blue Cross and Blue Shield Nebraska (BCBSNE) will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same health care system or under the same provider contract.

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.

Claims denied with code MP27

Final determination cannot be made until we receive the physician’s office records. The patient’s history, physical and physician’s notes and/or plan of treatment, should not be sent via paper Reconsideration form or through the electronic NaviNet^® submission.

• If sent as a reconsideration with medical records, either on paper or via the electronic NaviNet submission, they are being returned
• Providers must fax the medical records with the letter they received from our Medical Support Department
• By not sending the letter with the requested records to the correct location (below), it will result in a delay:

Medical Support Department       TTY/TDO 711
PO Box 3248 Omaha Fax               402-392-4111
Omaha NE 68180-0001                  Toll Free Fax 800-991-7389

Gold Card Program Participant Reminder

As a reminder, we ask that all individuals who submit Gold Card procedures use the NaviNet preauthorization tool instead of sending in fax requests. NaviNet provides automatic approval for the Gold Card codes. If you are currently utilizing the NaviNet preauthorization tool to submit Gold Card procedures, thank you!

Online Resources: Please locate the online training resource for the new tool at NebraskaBlue.com

Quick Reference Guide: Gold Card-specific step-by-step guide on submitting a preauthorization in NaviNet

Gold Card Quick Reference Guide 

Who to contact: 

• Gold Card related questions: Kathy.Lee@NebraskaBlue.com 
• Preauthorization Tool questions: 1-800-247-1103, option #6, ProviderPortalAuthQuestions@NebraskaBlue.com
• NaviNet or Provider Executive questions: NebraskaBlue.com

Access and Availability Standards

To comply with regulatory requirements, BCBSNE has established appointment access and availability standards. To meet access standards, BCBSNE has in-network providers representing multiple specialties across the state of Nebraska. As an in-network provider, you agree to maintain the appointment availability standards to ensure timely access to care for our members. 

The next telephone survey to evaluate compliance with the appointment availability standards is scheduled for the first quarter of 2024.  

Please review the appointment availability standards at NebraskaBlue.com/Providers/Credentialing.   

When reviewing the appointment availability standards, please pay special attention to the following appointment types. 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).

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

 

Multiple Procedure Adjustments for Radiology Payment: Coming the end of the first quarter of 2024 

Medicare’s National Physician Fee Schedule (PFS) is a listing of CPT procedure codes sorted and ranked by their relative weight, meaning the average time a provider would take to perform the procedure, along with the expense involved in performing it. This ranking provides a recommended payment based on the relative value unit (RVU) of work. Procedures valid for Multiple Procedure Payment Reduction (MPPR) can be identified under Column S, Mult Proc, of the PFS Relative Value File.

CMS created guidelines under the MPPR to handle scenarios where multiple procedures are performed on the same patient on the same date of service. Per MPPR guidelines, multiple procedures are ranked according to RVU and paid in descending order of highest to lowest RVU. The highest-ranked procedure receives 100% payment, with the second and subsequent lower-ranked procedures receiving a reduced payment. 

Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual explains, “Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often an overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work.”

BCBSNE currently aligns with CMS’s MPPR guidelines for therapy procedures and will apply the MPPR to radiology procedures the end of the first quarter of 2024. Please continue to review future issues of the Update newsletter for more information.

Resources:

• CMS transmittal R11940TN
• National Physician Fee Schedule Relative Value File 

Reminder—Overpayments and Refund Offsetting

BCBSNE requires a refund offsetting process for in-network providers. If you identify a claim overpayment has been made, please follow the claims adjustment process by submitting a Reconsideration via the NaviNet Claim Appeal process.

Please do not send a check/payment as the recoupment will be satisfied with a refund offset.

Note: If the offset is due to an overpayment of a Federal Employee Program (FEP) claim, offsetting will only occur on other FEP claims. We will not offset overpayments on FEP claims with claims that are non-FEP.

Read the Refund Offsetting (GP-X-095) policy.

Provider Directory: Make Sure 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 review directory information in NaviNet. Directory information is located under Practice Documents in NaviNet and updated information will be available on Nov. 27, 2023. Please take a few minutes to review your online directory information to help ensure BCBSNE members can locate your most current information. 

For PHO groups handling their own credentialing processes, please continue submitting a full roster every 90 days. 

Streamlining the Process for Provider Directory Updates

The federal No Surprises Act of 2021 and Blue Cross Blue Shield Association require BCBSNE to maintain and update provider directory information within a specified timeframe. Our current processes to update directory information using forms, spreadsheets, and emails adds administrative work for your office and does not allow BCBSNE to meet the required timeframes. 

To streamline and improve this process, BCBSNE will begin using the CAQH (Council for Affordable Healthcare) directory solution, called DirectAssure. DirectAssure works with the CAQH Provider Data Portal, formerly known as CAQH ProView. The CAQH Provider Data Portal enables providers to submit professional practice information and share it with multiple health plans, eliminating the extra work your office does today to also send the changes to us. 

In the CAQH Provider Data portal, you will be able to: 

• Review, correct, and update information 
• Confirm information is correct by attesting to its accuracy 
• Keep information current by updating directory date as changes take place
• Attest to the accuracy every 90 days from the last attestation period to indicate the data is still current (will replace need to review directory information in NaviNet) 

Today over 85% of in-network providers have a CAQH profile. If you do not have a profile, we recommend creating one as soon as possible in preparation for this change. There is no cost associated with this new process. For more information on creating a profile and using the CAQH Provider Data Portal please visit Proview.caqh.org.

We are planning to roll out the new process after the start of the new year. Additional information and training resources will be available on the Provider Academy. If you are affiliated with a PHO, your Provider Executive Representative will be reaching out with additional information. 

^{DirectAssure is a provider directory solution that works with the Council for Affordable Healthcare (CAQH) Provider Data Portal.  ©2023 CAQH}

Preauthorization Requests

The 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 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 setting up the request. 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 to review the request. 
• 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 fax number, 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 for who submits the request. 
• Procedure and diagnosis information

Preauthorization and Precertification: Do they mean the same thing?

For BCBSNE, preauthorization and precertification do not mean the same thing.

Preauthorization applies to certain types of care and services that are required to be preauthorized prior to the service being performed.

Examples of care and services that require preauthorization include surgical procedures, prescription drugs and durable medical equipment. For a full list of care and services requiring preauthorization for BCBSNE members, please access the MedPolicy Blue tool. 

Precertification applies to acute care (non-emergency) inpatient and observation admissions to hospitals or facilities on or before the first day of admission.  

Precertification applies to skilled nursing facility admissions, inpatient physical rehabilitation, services such as home health nursing visits and hospice care, and inpatient mental health and residential admissions. Labor and delivery hospital stays (48 or 96-hour admissions) are excluded from this requirement. 

Precertification is completed in NaviNet^®

NOTE: If a patient will be admitted as inpatient or observation and the procedure also requires preauthorization, both a preauthorization and an inpatient/observation request must be submitted through NaviNet.

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

Medicare Advantage Claim Submissions

When submitting 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.

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.

The covered visits are the annual physical exam, Annual Wellness Visit or “Welcome to Medicare” preventive 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

Resources:

Eye Exam for Patients with Diabetes (EED)
Hemoglobin A1C Control for Patients with Diabetes (HBD)
measures for diabetic patient health^®HEDIS 

Medicare Advantage: BMI Misconceptions in Coding

When coding for BMI, it is widely believed that if the BMI is listed in the vitals that is all that is required for coding. When it comes to Medicare Risk documentation, it is important to show BMI percentage in the vitals, more importantly Morbid Obesity needs to be documented in the healthcare provider’s own words.

For many people who carry excess weight, losing 5% to 15% of their total weight can improve some weight-related issues. Morbid Obesity can contribute to conditions such as Heart disease, Type 2 diabetes, prediabetes, Asthma (Reactive airway disease), High Blood Pressure, Obstructive Sleep Apnea (OSA), High Cholesterol, Non-Alcoholic fatty liver disease (NAFLD), Polycystic Ovary Syndrome (PCOS) and Osteoarthritis (OA).

BMI is only used for guidance not a dx, the healthcare provider must document, address, and state the plan. Coding Professionals should not assume a diagnosis unless stated by healthcare provider. 

E66.01 - Morbid Obesity due to excess calories
E66.09 - Other Obesity due to excess calories
E66.2 - Morbid Obesity + OSA + Hypercapnia (body unable to get rid of carbon dioxide in system)
E66.3 - Overweight

It is appropriate in Risk Adjustment to abstract and code Obesity or Morbid Obesity if it is documented anywhere in the chart!

When calculated BMI and the reported dx do not match (for example BMI is 37 and documentation states Morbid Obesity) the condition documented by the healthcare provider will always trump the BMI reported.

BMI codes are not intended to be reported alone without documenting the severity of obesity. 

Small victories go beyond losing weight. By sticking to a plan and setting new goals for the road ahead, weight loss could offer improvements in: Energy levels, moderate to vigorous activity, walking, climbing stairs, kneeling, or chores, such as carrying groceries and overall mood.

Clinical Interpretation of Body Mass Index (BMI) Values

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.

Did You Know you can self-service most of your claim administration in NaviNet

On the Claim Status Detail page, you can see claim progress and outcomes, view claim return letters, submit Appeal, Reconsideration, and Timely Filing Disputes, as well as Claim Investigations.

Remittance Advices from the past two years can be obtained through the Workflows menu.

Do not submit BCBSNE Medicare Advantage (Y2M or YMA prefixes) appeals, reconsideration, or timely filing disputes via NaviNet.  

For first-level appeals, reconsiderations, and timely filing please send requests directly to:

Blue Cross and Blue Shield of Nebraska
Medicare Advantage PRS-Appeals
PO Box 44317 
Detroit, MI 48244-0317     

For second-level appeals, please send requests directly to:

Blue Cross and Blue Shield of Nebraska
PO Box 441335
Detroit, MI 48244-1335

 

Security Corner

Security Corner: Culture of Security

Create a culture of security by implementing a regular schedule of employee training. Update employees as you find out about new risks.

Some training topics around protecting physical PHI are always important. These topics could include:

• Shred documents. Always shred documents with sensitive information before throwing them away.
• Erase data correctly. Use software to erase data before donating or discarding old computers, mobile devices, drives, etc. If you have a third-party vendor do this for you, be sure to get a certificate from them that notes the compliant destruction of the data.
• Promote security practices in all locations. Maintain security practices even if working remotely or at another clinic location.
• Know the response plan. All staff should know what to do if equipment or paper files are lost or stolen, including whom to notify and what to do next.