Medicare Advantage

We recently communicated a change in the management of certain drugs under the medical benefit for Medicare Advantage (MA) members. The prior authorization requests can be submitted via web exclusively through GatewayPa.com. The MA Part B drug request form has been retired and you will no longer be able to submit these prior authorizations via fax.

Thank you for your continued support in ensuring our members receive high-quality and clinically appropriate care.

We are delighted to offer our Medicare Advantage members the ability to fill prescriptions for 100 days in 2025.    

Filling maintenance medications for 100 days at a time is not only convenient but also helps patients stay adherent to their treatment plans and take their medications as prescribed by their healthcare provider.

Medicare Advantage dental plans are reimbursement policies only. Members pay the full amount to the provider and then they will submit a claim for reimbursement.

In order to assist your patients please consider providing them with documentation that includes your TIN and NPI numbers. This will make filing and reimbursement easier for them.

Reimbursement amounts vary by plan:

• Core HMO is $1,950.00
• Connect PPO is $1,500.00
• Access PPO is $2,050.00
• Secure PPO is $2,050.00

All plans have no deductible, and covered services must be performed by a licensed dental provider. Please contact the member to confirm which dental plan they have.

BCBSNE conducts settlements on hospital claims for BCBSNE Medicare Advantage (MA) members. This applies to in network Critical Access Hospitals and Rural Health Clinic providers. Below are a few FAQ reminders on the MA interim reimbursement letters.

How do I submit my MA rate letter provided by CMS?

• Please email the CMS MA rate letter to ProviderExecs@NebraskaBlue.com.

When do I need to submit these requests?

• Rate letters must be submitted within 60 days of being published by the MAC.

For more information on this procedure please see MA Critical Access Hospital Cost Settlement for In-Network Providers.

For MA 2024-2025 outpatient, professional and CAH swing bed claims with charges incurred during different years, the charges must be submitted on separate claims.  

For example: 

• If dates of service are from Dec. 15, 2024, to Jan. 15, 2025: 
• Submit charges incurred from Dec. 15, 2024, to Dec. 31, 2024, on one claim 
• Submit charges incurred from Jan. 1, 2025, to Jan. 15, 2025, on a separate claim 

Claims submitted with charges incurred during both years on the same claim will be rejected back to the provider to split the claim. 

When submitting Medicare Advantage claims, CMS standards must be followed to prevent unnecessary returns and processing delays. Effective June 4, 2024, with the CMS edits in place you will see non-Nebraska MA claims process more appropriately.

Beginning November 26, 2024, we will begin adjusting claims appropriately prior to June 2024, in accordance with the MA adjustment language. Providers can expect to see these adjustments reflected throughout December 2024 and January 2025.

Please do not submit Reconsideration Requests for claims you believe did not pay correctly. We will be running reports to determine if adjustments or recoupments are needed. Reminder, claim return letters are now available in Plan Documents on NaviNet^®.

Below are three common CMS standards that would need to be followed to avoid claims being returned or denied. 

DME NU & RR Modifiers

• Claims that are billing supply codes with NU modifier, and they do not require an NU modifier, will be denied.
• If billed without BP and BR modifiers that go with certain rentals, they will be denied as well.  

Federally Qualified Health Centers (FQHC) and Rural Health Claims

• Per CMS guidelines Medicare Advantage FQHC and Rural health claims will need to be billed on a UB04 instead of on a CMS 1500 form.
• We were not enforcing before and are now and will be returning or denying claims as appropriate. 

Ambulance for MA only

• Per CMS guidelines, ground mileage totaling up to 100 covered miles must be reported to the nearest tenth of a mile.  In addition, all air ambulance mileage must be reported as fractional units to the nearest tenth of a mile.   When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile.
  • Professional Electronic – When submitting fractional units, the Provider needs to submit the same fractional units in the Ambulance Mileage field on the 837P AND the units field.
  • Professional Paper (CMS-1500) – When submitting fractional units, the Provider needs to submit the fractional units in the units field.
  • Institutional Electronic – When submitting fractional units, the Provider needs to submit the fractional unit in the units field. There is not a separate Ambulance Mileage field on the 837I for Institutional.
  • Institutional Paper (UB-04) – Providers should continue to submit whole units as decimals are not allowed on the UB in the units field.
• Claims will be returned if not submitted correctly. 

The Medicare Prescription Payment Plan, also referred to as M3P, is a new payment option starting in 2025 for Medicare members that works with their current drug coverage and can help them manage their prescription drug costs by spreading them across monthly payments that vary throughout the year (January – December).

This payment option might help them manage their expenses, but it doesn’t save them money or lower their drug costs. All Medicare members are eligible to participate in this payment option, regardless of income level, and all Medicare drug plans and Medicare health plans with drug coverage must offer this payment option.

If your Medicare patients have any questions, they can contact us at 855-457-1349 or visit Medicare.NebraskaBlue.com to find out more about the new Medicare Prescription Payment Plan.

When a decision is made on a Medicare Advantage (MA) preauthorization, the decision letters will only include the codes that were submitted on the authorization. The family of codes will not be included on these MA letters.

Currently the Medicare Advantage (MA) Procedures are housed as PDF documents on our Medicare Advantage Policies page. As we begin moving our support of our MA program fully in house, we will also be updating how the MA Provider Procedures are delivered in 2025.

Effective Jan. 1, 2025 you will be able to use the BCBSNE Provider Procedures search tool to locate MA procedures. When searching for a MA procedure with a keyword in this tool, you can filter the policies by selecting the Medicare Advantage tag on the left-hand side of the search results.

For more information on the BCBNE Provider Procedures you can review the eLearning under the Provider Academy.

We’re excited to announce that in 2025, we will bring the operations of our Medicare Advantage (MA) program fully in house, providing key benefits for you, our health care provider partners.

What’s changing? 

Currently, BCBSNE works with a third-party vendor to manage our MA program. Effective Jan. 1, 2025, we will bring the operations of our MA program fully in-house. This change will enable us to better support you, our health care provider partners, in serving your patients who have a BCBSNE MA plan. Key benefits will include:

Utilization Management: 

• Providers will be able to submit MA preauthorizations via NaviNet^®. These preauthorizations can be tracked in the same way as our commercial members' preauthorizations.
• The types of preauthorizations able to be submitted via NaviNet will be expanded for MA plans.
• Discharge planning will be managed directly by BCBSNE.
  
   

Claims processing: 

• BCBSNE will process MA claims directly. You can expect the claims process for MA to mirror BCBSNE’s familiar commercial claims process. This will allow BCBSNE to provide you with an enhanced experience, as our Provider Executive team will have increased visibility into claims and be able to support you should you have questions.

Enhanced customer service experience: 

• BCBSNE will have a Nebraska-based customer service team available to answer MA questions once the transition is complete. Please note: The customer service phone number for MA will not change. Please continue to call 888-505-2022 for BCBSNE MA member eligibility, benefits and claims questions.

Access to Medicare Advantage on NaviNet: 

• After the transition is completed on Jan. 1, 2025, providers will have access to claims, eligibility, benefits, preauthorization and other items available on NaviNet for the Medicare Advantage line of business.

We will share more information about this change soon. If you have any questions in the meantime, please reach out to your Provider Executive. 

BCBSNE is pleased to announce beginning Jan. 1, 2025, we will waive authorizations the first 7 days in a Skilled Nursing Facility (SNF) for all MA PAR providers. Notification of Admission is required within 72 hours of admission. Concurrent authorization review is required to certify additional days, thus allowing us to issue the Notice of Medicare Non-Coverage timely to the facility and the member. 

If a SNF admission goes beyond 7 days; authorization will be required on day 8 and after. BCBSNE is committed to the health and well-being of our members and communities we serve.

1^st Level Appeals:

BCBSNE Provider Correspondence
PO Box 21501
Eagan, MN 55121

Fax: 210-579-6930

2^nd Level Appeals:

BCBSNE Appeals & Grievances
PO Box 21831
Eagan, MN 55121

Fax: 1-877-482-9749

For additional information regarding Nebraska Medicare Advantage plans, refer to the Medicare Advantage policy page.