What is NEtwork BLUE?
NEtwork BLUE is Blue Cross and Blue Shield of Nebraska’s PPO network. This network serves as the foundation for all of our business.
NEtwork BLUE providers can access claim status information, as well as remittance advice information for a processed claim, by logging into NaviNet (www.navinet.net/solutions/plans/bcbsne). Information is also made available to providers through our telephone voice response system at 800-635-0579. Providers who have not signed an agreement with BCBSNE are not able to access claim information telephonically.
As a Participating Provider in NEtwork BLUE, you will receive direct payment for covered services in accordance with your provider agreement. Claims from non-participating providers are paid to the member.
Notification of Disposition
You always know when a claim is paid, how much is paid and what the patient’s liability is because you receive our remittance advice.
We actively promote our health care professionals and facilities. Provider access information is continuously updated on local, national and group websites for customers to review when making a selection. Up-to-date provider directories are available to our customers at www.nebraskablue.com. Members who obtain covered services from network providers have lower out-of-pocket expenses and receive the highest level of benefits.
You can rely on our excellent reputation in the industry and the community. We’ve done business in Nebraska for over half a century. Our network consultants and physician reviewers who help develop our policies are also BCBSNE network providers. We work jointly with our health care professionals in providing the best health care possible to our customers.
How to Participate?
To participate in NEtwork BLUE, complete the credentialing process and sign a NEtwork BLUE agreement. All NEtwork BLUE applicants must go through the credentialing process and satisfy all credentialing requirements prior to being accepted into the PPO network. Note: BCBSNE cannot credential a provider who holds a temporary Nebraska state license.
BCBSNE entered into an arrangement with the Council of Affordable Quality Healthcare (CAQH), as part of an initiative to obtain professional credentialing information electronically. The Council offers an electronic application that can be completed online, and because CAQH is used by some other insurance companies, using CAQH will reduce some of the administrative duplication of efforts related to credentialing.
Provider offices that have already been supplying information to CAQH will want to verify that BCBSNE has been granted access to the credentialing data and that the information stored by CAQH remains active and valid.
New practitioners wishing to join BCBSNE can complete the CAQH application and authorization directly to BCBSNE. More details about CAQH and the process to join are available at www.caqh.org
For more information regarding Credentialing and/or to request a Provider Agreement, please visit www.nebraskablue.com/providers/credentialing/
For questions pertaining to credentialing or to inquire about the status of an application, call or send an e-mail to:
Phone: 402-982-8293 or 800-821-4787 (option 4)
How do I know if I’ve been accepted in NEtwork BLUE?
Health Care Providers / Facilities whose applications have been approved for participation will be notified in writing.
Adding or Changing Practice Locations
If a Health Care Provider is already in our network and is adding a location with the same tax identification number, would like to extend their network status to an additional location with a different tax identification number while keeping the current/old location active, or is transferring network status to a new location under a new tax identification number, they need to complete a Provider Add/Extend/Transfer form. The form requires the practitioner’s signature and is available at www.nebraskablue.com by clicking the “Providers” button and then on “Forms for Providers” in the left column.
The Tax ID Number that should be listed at the top of the form is the one tied to the current practice location and existing BCBSNE Provider Agreement. All required fields must be completed prior to printing out and submitting the form to BCBSNE.
Submitting a Facility/Clinic Name Change
When a facility changes its name but keeps the same tax ID, ownership, location and providers, BCBSNE must be notified by letter or email (ProviderSolutions@nebraskablue.com) requesting the name be changed from [current name] to [new name] and include in the request the tax ID that the new name will appear under. If the facility has multiple NPI’s and lines of business (skilled nursing, home health, hospice, HME, etc.) those entities must also be listed in the request. The request needs to also include the effective date.
Tax Identification Number - Multiple Locations
As a network provider, you have agreed to file all claims to BCBSNE for any covered benefit provided to our members and to accept our payment as payment in full. If an office has multiple locations with multiple billing addresses, the provider will need to designate one payee location. BCBSNE policy is that all payment will go to one location since the offices share the same tax identification number.
National Provider Identifier (NPI)
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers. As a result, the Centers for Medicare and Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. BCBSNE also requires providers to use an NPI number when submitting claims.
Providers can apply for NPIs in one of three ways:
For the fastest receipt of NPIs, use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov and apply on line. To complete the paper NPI Application/Update Form, providers may obtain a copy of the form in any of these ways:
BCBSNE may designate an Onsite Review Coordinator to examine quality of care at an office where any issues of safety, privacy or environment have been brought to our attention. An assessment will be made by the Coordinator and a summary of findings will be provided to the provider. If corrective action is deemed necessary, a repeat visit will be scheduled.
This section includes information about the Bill Audit Program.
Standard Review Policy
BCBSNE reserves the right to perform a review or audit of any service provided to covered persons performed by physicians, hospitals, or other health care providers.
BCBSNE can conduct reviews to assess medical record completeness, quality of care, billing practices, and management of other applicable areas of concern to BCBSNE. Reviews may also be conducted as a part of BCBSNE’s Utilization Review Program. For example, a review may be part of a continued stay review, case management review, medical necessity review, DRG validation review or other review of services provided to members. These reviews may be conducted onsite, or BCBSNE may request documents to review at the BCBSNE site.
Health Care Providers agree to cooperate and assist with these efforts. BCBSNE agrees to abide by reasonable and non-obstructive practices. Reviews and audits will be conducted by BCBSNE staff or designated vendors acting on behalf of BCBSNE. The review may include inspection and duplication of any and all medical and other records applicable to treatment of a covered person necessary to determine liability and/or to verify performance. Only medical records of BCBSNE covered persons will be reviewed. Covered persons have consented to release medical records to us and an additional release is not required. All information resulting from a review is confidential.
BCBSNE reserves the right to require a NEtwork Blue physician, facility or other health care provider to comply with recommendations resulting from reviews or audits when noncompliance with BCBSNE utilization review criteria is identified.
Prepayment / Post-payment Review
The purpose of these reviews is to monitor and assess the accuracy of diagnosis and procedure coding as well as the medical necessity of services provided.
Claims subject to prepayment / post-payment reviews include, but are not limited to:
- All inpatient claims indicating a readmission within seven (7) calendar days are subject to review. Each readmission is reviewed in conjunction with the previous admission.
- All inpatient claims indicating a transfer to an inpatient facility.
- All outlier claims as identified by BCBSNE Bill Audit Department.
- All inpatient interim claims.
- Randomly selected outpatient claims.
- Medical/Surgical services performed in an office and/or patient’s home.
DRG Category Assignment
If the diagnosis/procedural code information submitted on an inpatient claim is determined to be incorrect following a review of pertinent parts of facility patient records, a DRG category regrouping will be made, and contract payment is adjusted. Notification of the regrouping is issued to the facility.
DRG Assignment Appeal
Facilities have the right to appeal the DRG regrouping assignment or associated payment. An appeal request must be submitted in writing. The appeal must include all documentation to support the request. Submit the appeal and all additional material to the following address:
Blue Cross and Blue Shield of Nebraska
Special Investigations Unit
Attention: Health Network Reimbursement, DRG Unit
P.O. Box 3248
Omaha, NE 68180-0001
Appeal information is reviewed by the Institutional Reimbursement staff. The appeal will be processed after receipt of all necessary clinical information. A written response will be issued within 30 calendar days.
Bill Audit Program
The audit process can be conducted as either a desk review of the pertinent records at BCBSNE or an onsite audit of the same records at the facility. If an onsite audit is performed, BCBSNE will contact the facility to schedule an appropriate audit date as soon as possible. BCBSNE will verify the mutually agreed upon audit date and time. An itemized statement and any applicable facility audit work papers are generally requested prior to scheduling the audit.
Preliminary Report Sheet and the Final Summary of Adjustments When an audit has been completed, a Preliminary Report Sheet is provided to the facility outlining the audit findings. Either BCBSNE or the facility may request an onsite exit interview, if desired.
Onsite Exit Interview:
If an onsite exit interview is requested, audit results will be reviewed with the facility within 30 days of completion of the audit findings. Upon completion of the exit interview, BCBSNE has fourteen (14) calendar days to return the Final Summary of Adjustments back to the facility.
After the receipt date of the Final Summary of Adjustments the facility has 14 calendar days to file a written appeal. If an appeal is not received by close of business on the 14th calendar day, the Final Summary of Adjustment will stand as final.
Process to Appeal Bill Audit Findings
The facility is required to submit a written appeal to BCBSNE. The appeal must state the specific reason for the dispute. Send the appeal and all required supporting documentation to the following address:
Blue Cross and Blue Shield of Nebraska
ATTN: Bill Audit/SIU
P.O. Box 3248
Omaha, NE 68180-0001
Required supportive documentation:
The appeal must be accompanied by any new or additional documentation from facility records to substantiate the facility’s position. This additional information must meet the following criteria:
The information must be relevant to the disputed issue(s), and
it must have existed during the dates of stay for the record in question, and
provide evidence based supporting documentation.
If the appeal contests the case review decision of the BCBSNE Medical Director or other BCBSNE physician consultant, the facility must provide its medical staff member or medical consultant written reply to BCBSNE for case review.
Peer-reviewed medical literature and other expert opinion may be included.
Level II Appeal Process – Upon communication of the appeal results, the facility has an additional 14 calendar days to submit a written notice of second appeal with additional supportive documentation. The Bill Audit staff will review the additional documentation. If the dispute is still unresolved, Bill Audit staff will forward documentation to the BCBSNE Medical Director or other BCBSNE Physician Consultant. Once Physician/Medical Director decision is made, documentation for that decision will be returned to the Bill Audit Department to communicate the appeal results back to the facility.
Level III Appeal Process - Upon communication of the appeal results, the facility has an additional 14 calendar days to submit a written notice of third appeal. This is the highest and final level of appeal. This appeal process will consist of a Grievance Panel of Committee Members. That panel includes a minimum of:
Outside Physician and / or Registered Nurse,
the BCBSNE Appeals Department,
BCBSNE Administrative Representative, and a
This committee is dictated by the State Appeal Laws of Nebraska.
Bill Audit Provisions
- All BCBSNE policies and procedures, medical policy, and Provider Agreements are considered while reviewing medical records. BCBSNE medical policy includes, but is not limited to: medical necessity policy and investigative policy.
- In no case will an audit be scheduled beyond one year from the final payment date.
- Once a claim has been selected for audit review, the facility should not submit a replacement or corrected electronic or paper claim nor should one be submitted at any time during or after the review process.
- Standing orders or care protocols must be available for review. 11 Return to Start of Section Proceed to Next Section Go to Table of Contents
- Charges for nursing and/or ancillary personnel care that do not include supplies are not considered billable services and will be removed from the charges prior to calculation of negotiated reimbursement methodology. These services are not billable to the member.
- Issues identifying lack of appropriate documentation to support billed charges may result in recommendations by our audit staff to address a corrective action plan. These recommendations are noted in the Final Report Letter. Effective for dates of services three (3) months after such recommendation, continued absence of appropriate documentation supporting billed charges will result in disallowance of those charges.
- When BCBSNE medical policy determines an item or service to be investigative or experimental, the item(s) or service(s) considered noncovered services will be deducted from the total charges prior to calculation of reimbursement methodology. These noncovered services may or may not be billed directly to the member.
Examples of Nonbillable Facility Charges
The list below contains examples of nonbillable facility component charges. This list is NOT an all-inclusive list of nonbillable charges.
Nonbillable charges are removed from the total charges before calculating reimbursement. Nonbillable services may not be billed to the member.
- Administration of blood products or medications
- After-hours, On-call, stand-by, emergency call or stat charges - e.g., Lab, EKG/EEGs, X-ray, CT Scan, U/S, Nuc. Med., O.R.
- Blood service charges
- Bone marrow collection or aspiration
- Bronchoscopy assist
- Catheterization technical services
- Charges for nursing and/or ancillary personnel care that do not include supplies
- Code 99, CPR, or unscheduled cardioversion
- E.R. patient assist or transport
- Insertion of catheters, i.e., arterial, Groschong, central line, PICC, IV, foley, nasogastric
- Incentive spirometry or MDI treatment
- Kinetic consult or monitoring
- Manual ventilation
- Medication mixing fees
- Nasal tracheal, tracheal tube suction or aspiration, cough induction, suctioning, secretion induction
- Patient assessment
- Patient assistance
- Patient education or teaching 12 Return to Start of Section Proceed to Next Section Go to Table of Contents
- Patient transportation
- Pathology tech assist or slide preparation
- Peritoneal lavage procedure
- Set-up charges e.g., ventilators, arterial lines, oximetry, etc.
- Swab specimen collection
- Therapist assist; PT/OT/Speech, Respiratory Therapist
- Vital sign monitoring
- Duplication of Therapeutic Services