Reimbursement

Blue Cross and Blue Shield of Nebraska (BCBSNE) reimburses network providers at the reimbursement level stated in the provider’s Medicare Advantage agreements minus any member required cost sharing for all covered medically necessary services. 

Providers should collect any applicable cost-share from their members at the time of service or when possible. Cost-share refers to a flat-dollar copayment and/or percent coinsurance. Providers will be paid the lesser of the allowed amount or the provider’s charge, minus the member’s cost-share. This represents payment in full and providers are not allowed to balance bill members for differences between the allowed amount and charges. 

BCBSNE provides an Evidence of Coverage to all members following enrollment. This document provides general benefit information for members by plan option. It also describes member cost-sharing requirements. 

Original Medicare benefit coverage rules apply, except where noted. BCBSNE will not reimburse providers for services that are not covered under Original Medicare unless such services are specifically listed as covered services under the member’s Medicare Advantage Plan. 

BCBSNE must also comply with CMS’ national and local coverage determinations, general billing guidelines included in Original Medicare manuals and instructions and written coverage decisions of the local Medicare Administrative Contractor. 

Providers must follow all Original Medicare billing guidelines and include the following on all claims: 

• Diagnosis code(s) to the highest level of specificity. When a sixth or seventh digit exists for a code, all applicable digits must be supplied. 
• Medicare Part B supplier number, National Provider Identifier (NPI) and federal tax identification number. 
• The member’s BCBSNE Medicare Advantage number, including the alpha prefix, found on the member’s ID card. 
• For paper claims, the provider’s name should be provided in Box 31 of the CMS-1500 (02/12) claim form. 

Providers affiliated with the Medicare Advantage network agree to BCBSNE reimbursement policies outlined in the Medicare Advantage agreement. These include: 

• Accepting the applicable Medicare Advantage plans agreement as payment in full for covered services, except for cost-sharing, which is the member’s responsibility. 
• Billing BCBSNE, not the patient, for covered services 
• Providers are not allowed to balance bill the members for any covered services.  
• Not billing patients for covered services that: 
  • Require, but did not receive, preapproval. 
  • Were not eligible for payments as determined by BCBSNE based upon our credentialing or privileging policy for the particular service rendered.