Medicare Advantage

Blue Cross and Blue Shield Nebraska (BCBSNE) is committed to providing our members with access to high-quality health care that is consistent with evidence-based, nationally recognized clinical criteria and guidelines. Therefore, we will be implementing a change in the way we manage certain specialty drugs that fall under the medical benefit for our Medicare members. This new program will be administered by the Medical Pharmacy Solutions team at Prime Therapeutics (Prime).

Beginning Jan. 1, 2025, providers should begin contacting Prime to obtain prior authorizations for the in-scope drugs for our Medicare members with dates of service on or after Jan. 1, 2025. 

You will be able to complete the prior authorization process via NaviNet^® or phone. Prior authorization will be required for the medical specialty drugs when they are administered in the following settings: 

• Physician Office (POS 11)
• Patient Homes (POS 12)
• Outpatient Facilities (POS 19, 22)

The Medical Pharmacy Solutions team at Prime Therapeutics (Prime) will be hosting web-based training sessions in Nov. of 2024. Please watch your email and our Medicare Advantage Happening Now page for updates and additional information.

Blue Cross and Blue Shield of Nebraska has expanded its partnership with Evolent (formerly National Imaging Associates, Inc) to include Blue Cross and Blue Shield of Nebraska Medicare Advantage members for the Musculoskeletal (MSK) and Interventional Pain Management (IPM) authorization programs that have existed for commercial members since 2015. Evolent’s MSK and IPM Solutions programs are intended to help providers effectively deliver quality patient care.

Evolent is an independent company providing MSK and IPM solution programs for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.

Effective Jan. 1, 2025, MSK and IPM services will require prior authorization through Evolent prior to being rendered in an inpatient or outpatient setting (MSK) or outpatient facility/office setting (IPM). Providers may begin contacting Evolent on Jan. 1, 2025, to seek prior authorization for procedures scheduled on or after Jan. 1, 2025. This prior authorization management program applies to your Blue Cross Blue Shield of Nebraska Medicare Advantage members. 

Evolent uses clinical criteria based on nationally recognized guidelines to promote evidence-based practices. 

The Evolent program will apply to all specialties for the following non-emergent inpatient and outpatient MSK surgeries: 

Lumbar

• Lumbar Microdiscectomy
• Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy and Foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
• Lumbar Artificial Disc Replacement – Single and Multiple Levels

Cervical

• Cervical Anterior Decompression with Fusion –Single and Multiple Levels 
• Cervical Posterior Decompression with Fusion –Single and Multiple Levels
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement – Single and Multiple Levels
• Cervical Anterior Decompression (without fusion)  

The Evolent program will apply to all specialties for the following outpatient IPM procedures: 

• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)

Prior authorization requests for MSK and IPM services can be submitted to Evolent:

• Via Evolent provider portal at RadMD.com 
• Via telephone at 1-800-424-4956. Staff is available Monday - Friday from 7 a.m. to 7 p.m. CST.

RadMD offers providers the ability to: 

• Request prior authorization and verify authorization status. 
• Upload required clinical documentation and view submitted files. 
• Access clinical guidelines, checklists and additional provider resources and tools.
• Identify the dedicated Evolent Provider Solutions Manager to use as a direct point-of-contact for any issues or questions.

Blue Cross and Blue Shield of Nebraska Medicare Advantage approvals issued before Jan. 1, 2025, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. For services/treatment that did not require an authorization prior to Jan. 1, 2025, an authorization may be required from Evolent for service/treatment dates on and after Jan. 1, 2025. 

Any Blue Cross and Blue Shield of Nebraska Medicare Advantage prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the service has met Evolent’s medical necessity criteria. 

Blue Cross and Blue Shield of Nebraska Medicare Advantage is proud to be your health care partner. If you frequently request MSK and/or IPM services and are new to this process, please register for a training session.

Tuesday Nov. 19, 2024
8 a.m. CST
https://zoom.us/meeting/register/tJUtdOmhqDotHdZmQBtQEHINbEwWoDGpseSc

Thursday, Nov. 21, 2024
12 p.m. CST
https://zoom.us/meeting/register/tJMkcuyvqzooGdDmBmd_jF7t9dxpYhKS3Wat


Tuesday, Dec. 10, 2024
12 p.m. CST
https://zoom.us/meeting/register/tJAsduigqTkjH9aGtZzYFxiYLWpibxZIpKZk

Thursday, Dec. 12, 2024
8 a.m. CST
https://zoom.us/meeting/register/tJ0odemhrjwtHtLFm7xzMXg3WeKBkmCYMCci

Telephone:

• +1 305 224 1968 US
• +1 646 931 3860 US

Meeting ID for Tuesday, Nov. 19, 2024, at 8 a.m. CST:    ID# 910 3096 1772
​Meeting ID for Thursday, Nov. 21, 2024, at 12 p.m. CST:    ID# 979 5575 1234
​Meeting ID for Tuesday, Dec. 10, 2024, at 12 p.m. CST: ID# 941 1187 2952
​Meeting ID for Thursday, Dec. 12, 2024, at 8 a.m. CST: ID# 995 2090 7746

If you have questions, please contact Blue Cross and Blue Shield of Nebraska Medicare Advantage Provider Services Department at 1-888-505-2022. If you have questions about Evolent MSK or IPM programs, please email RadMDSupport@Evolent.com or call 1-800-327-0641. 

We look forward to offering you this program and hope it will enhance your experience with MSK and IPM authorizations. 

BCBSNE is excited to inform you that all current BCBSNE Medicare Advantage members will receive a new member ID number, effective Jan. 1, 2025.

Key Points to Remember:

•  New ID Cards: Members could begin to receive new ID cards in the mail by early October.
• Prefix for New ID Cards: To help identify which ID card is the new one for Jan. 1, 2025, the prefix will be different.
  
  • YMA4 will be the new prefix for the HMO product instead of YMAN.
  • Y2M4 will be the new prefix for the PPO product instead of Y2MN.
• Effective Date: These new ID numbers will not be valid until January 1, 2025.
• Usage: Please note that the new ID numbers should be used for services on or after Jan. 1, 2025.

If you receive a new ID number from a current BCBSNE Medicare Advantage member, please remember that it will only be effective for dates of service from Jan. 1, 2025, onwards.

Thank you for your attention to this important update!

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.

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. 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. professional claims should be sent to Medicaid, NaviNet Eligibility and Benefits and category "Hospital - Inpatient" will show "Not Covered". Claims should be sent to Medicaid. 

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
  • If a claim is submitted with the same NPI in both box 24J and 33A the claim will reject
• Submit claims for prefixes YMA and Y2M with a street address in the billing address field, claims submitted with PO boxes will reject
• Host claims will return when the facility ZIP codes is missing from Box 32

Effective January 1, 2024, Carelon will add the following new code to prior authorization. This is a new CPT code for 1/1/2024.

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.