Medicare Advantage

We're excited to announce that in 2025, operations of our Medicare Advantage (MA) program are fully in house. 

The information on this page is available for those providers who are Medicare Advantage-contracted with Blue Cross and Blue Shield of Nebraska (BCBSNE).

Stay up-to-date with the changes in the Provider Update Newsletter. Read more »

Quick Links to MA Resources
 Provider Procedures     Provider Academy     Provider FAQs     Forms

For Medicare Advantage eligibility, benefit or claims questions call 888-505-2022. *


Important Information and MA Happening Now Updates

Identity theft is a growing concern in healthcare, where sensitive personal and medical information is handled daily. Implementing robust identity theft precautions is crucial to safeguard patient information and maintain trust. One effective practice is verifying photo IDs, which plays a significant role in preventing identity theft and ensuring accurate patient identification.

Benefits of Photo ID Verification

  • Accurate Patient Identification: Ensures the person receiving care is the patient on record, reducing medical errors.
  • Enhanced Security: Adds an extra layer of security, making it harder for individuals to use stolen identities.
  • Improved Trust and Confidence: Patients feel more secure knowing their information is protected, building trust in the provider-patient relationship.

By incorporating these measures into your daily operations, you can significantly reduce the risk of identity theft and enhance the overall patient experience.

We are excited to share an important update regarding the verification of coverage for our members. With our recent enhancements, you can now accurately verify coverage using just the member’s name and date of birth. This means you no longer need the prefix and Card ID number to confirm active membership with our BCBSNE members.

We appreciate your attention to detail in ensuring our members receive the best service possible. Thank you for your continued dedication and support. 

In order to obtain proper reimbursement for Medicare Advantage (MA) claims, please follow Original Medicare billing and coding guidelines. This information can be found at CMS.gov, searching for the appropriate topic. 

Effective Jan. 1, 2025, BCBSNE began the new process to automatically approve 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.

Notification of Admission:

  •  Can be provided via NaviNet by submitting an authorization, allowing access to the authorization if a continued stay review is needed.
  • If continued stay review is needed, you can access the authorization to conduct your review via NaviNet, but only if the initial review was submitted via NaviNet.

Alternative Notification Methods:

  • Fax to the UM fax line: 1-866-422-5120
  • Call the UM phone line: 1-877-399-1671

Concurrent Authorization Review:

  • Required to certify additional days.
  • Ensures timely issuance of Notice of Medicare Non-Coverage to the facility and the member. 
  • If faxing the medical records, please fax the documents by noon the day they are due to maintain timeliness of the review.

BCBSNE is committed to the health and well-being of our members and communities we serve.

The MA Provider Service phone line will be closed for department meetings as they are for commercial. Below are the upcoming hours that the MA Provider Service phone line will be closed.

Feb. 25. 2025 - 9:45 a.m. to 12:30 p.m.

Every Wednesday from 9 a.m. to 10:30 a.m.

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 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 began to receive new ID cards in the mail Nov. 2024.
  • Prefix for New ID Cards: To help identify which ID card is the new one for Jan. 1, 2025, the prefixed 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.
  • NaviNet: Please be advised NaviNet may display the new ID number as active prior to Jan. 1, 2025. However:
    • 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.

Blue Cross and Blue Shield of Nebraska (BCBSNE) has discovered Medicare Advantage (MA) 27x transactions are only giving specialist copay information. The PCP copay information is missing, leading providers to request that MA members pay the specialist copay in error.  We are working on this issue but do not currently have an ETA. For BCBSNE MA PCP providers, please do not charge a copay to members based on the 271 eligibility response transactions until this is resolved.  

Updated EOPs will be sent once a fix is in place. Continue to watch the MA Happening Now for updates.

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?

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. 
 
 

 

 

 

*MA Provider CSC hours of operation: Monday- Friday from 8 a.m. to 7 p.m.

 

 

 

 Y0139_MAPrvdrWeb_C