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Provider Update January 2025

Welcome to our new Update Newsletter format where information for our medical, dental and Medicare Advantage products is included in one publication.

General Information

Reminder: Updating NPPES data registry
Our Medicare pricing tool uses the NPPES data registry to link the Medicare Number/CCN with the NPI data listed in the registry. If there is a discrepancy between the data in the registry and what is submitted on the claim, the claim may be delayed or potentially returned. Therefore, it is crucial for providers to ensure accurate updates to the NPPES and to deactivate outdated information.
HEDIS® Medical Record Reviews

From February through May each year, Blue Cross and Blue Shield of Nebraska (BCBSNE) conducts medical record reviews to gather essential Healthcare Effectiveness Data and Information Set (HEDIS) measurement quality data for our members. This process is crucial for assessing the quality of care provided to our patients.

Data Collection Process:
Commercial Members: Data is collected using Reveleer®.

Medicare Advantage Members: Data is collected through Datavant Health.

Both Reveleer and Datavant Health will reach out to your clinic to request specific clinical details that may not be included in claims data, such as: Blood pressure readings, HbA1c lab results and Colorectal cancer screenings.

Your cooperation in providing these records is vital. It not only helps us meet our quality goals but also enhances the overall health of our members — your patients.

Contractual Obligations:
As a participating provider, your contract includes provisions for supplying requested records to BCBSNE or our third-party vendors at no charge. We aim to minimize disruptions to your office workflow; therefore, prompt responses to these requests will reduce the need for follow-ups.

Thank you for your assistance in this important initiative. Your support is invaluable in helping us successfully complete our HEDIS reporting.

For more information on HEDIS, please visit NCQA.org.

BCBSNE provider networks are unique and specific to the member’s plan

BCBSNE offers a variety of provider networks to our Nebraska members to ensure access to their preferred providers and to help control costs. Ensuring you are in network for the member’s plan helps ensure the best benefits for your patients. When you are not in the patient’s plan network, their coverage level may be less, or your services may not be covered depending on their plan benefits.  

The member’s plan network is identified in the upper right corner on the member’s ID card. You can also see their plan network when verifying eligibility and benefits in NaviNet® under their product details. To learn more about verifying benefits and eligibility in NaviNet, watch our eLearning video.  


 
NEtwork Blue (NB) is our statewide network, made up of 98% of Nebraska’s doctors and 99% of the state’s non-governmental acute care hospitals.1 

NB provides access to: 

  • Hospitals and clinics across Nebraska 
  • Primary and specialty care providers 
  • Heart, cancer and trauma centers 
  • Children’s care 
  • Behavioral health network 

Premier Select BlueChoice (PSBC) is a regional network that features: 

  • Boys Town National Research Hospital - Downtown and Pacific Street
  • Children’s Nebraska
  • Madonna Rehabilitation Hospital Omaha
  • MD West ONE
  • Memorial Community Hospital
  • Midwest Surgical Hospital
  • Nebraska Medicine 
    • Bellevue Medical Center
    • Nebraska Medical Center
  • Nebraska Methodist Hospital System
    • Methodist Fremont Health
    • Methodist Hospital
    • Methodist Jennie Edmundson Hospital
    • Methodist Women’s Hospital
  • OrthoNebraska
  • SecureCare (chiropractors)
  • Select Specialty Hospital
  • Affiliated physicians and clinics

Lincoln Area

  • Beatrice Community Hospital
  • Bryan Health – East and West
  • Community Medical Center
  • Filmore County Hospital
  • Henderson Community Hospital
  • Howard County Medical Center
  • Jefferson County Hospital Center
  • Johnson County Hospital
  • Lincoln Surgical Hospital
  • Madonna Rehabilitation Hospital Lincoln
  • Mary Lanning Memorial Hospital
  • Memorial Hospital
  • Nemaha County Hospital
  • Pawnee County Memorial Hospital
  • Saunders Medical Center
  • SecureCare (chiropractors)
  • Select Specialty Hospital
  • Syracuse Area Health
  • Thayer County Health Services
  • York General Hospital
  • Affiliated physicians and clinics  

All other Nebraska providers are out of network.

Our Blueprint Health (BH) regional network features CHI Health and other providers and facilities in Nebraska and contiguous counties in Iowa. All other Nebraska providers are out of network.

Key hospitals and health care providers include:

  • Alegent Creighton Health Services
  • Boys Town National Research Hospital – Downtown and Pacific Street
  • CHI Health Creighton University Medical Center – Bergan Mercy
  • CHI Health Good Samaritan
  • CHI Health Immanuel
  • CHI Health Lakeside
  • CHI Health Mercy Council Bluffs
  • CHI Midlands
  • CHI Health Nebraska Heart
  • CHI Health Planview
  • CHI Health Richard Young
  • CHI Health Schuyler
  • CHI Health St. Elizabeth
  • CHI Health St. Francis
  • CHI Health St. Mary’s
  • Children’s Nebraska 
  • Lasting Hope Recovery Center
  • Lincoln Surgical Hospital
  • MD West ONE
  • Nebraska Spine Hospital LLC 
  • SecureCare (chiropractors)
  • Affiliated physicians and clinics

Medicare Advantage Network provides BCBSNE Medicare Advantage members access to over 6,000 providers across all specialties in the state of Nebraska. All BCBSNE Medicare Advantage members have access to the same robust network of providers in the Medicare Advantage Network regardless of the plan they are enrolled in. 

If you are not sure which network(s) you are contracted for, please visit our Find a Doctor tool.

For quick access, we added a link in NaviNet in the Resources section. 


 
After locating your provider, clinic or facility, you will see the Plans accepted in the fourth column. Click on the link here and then on the Medical and Dental Plans drop-down menu to see the list of networks.


 
For more information on Verification of Enrollment, please review our general policy. 

1 Source BCBSNE statistics, Oct. 17, 2023

Reminder: Timely filing requests transitioned to NaviNet

Effective Jan. 1, 2025, BCBSNE will no longer accept paper (faxed or mailed) timely filing override requests. As part of our ongoing transition to paperless processes, all timely filing override requests must be submitted via NaviNet.

Please note that we will no longer process or return paper timely filing override requests received via fax or mail.

Reminder: Emailing provider executives

Emails are handled in the order received; however, emails are not processed unless the below information is included.

  • Provider name, NPI and TIN
  • Claim numbers (if applicable)
  • Member name and ID
  • DOS
  • Expected outcome or reimbursement

Additionally, the appropriate steps MUST be followed first BEFORE submitting an escalation request to this email box:

Step One: NaviNet
Please access NaviNet for all member, claim, authorization and appeal needs. If you do not have access to NaviNet please register by following the steps on the Provider Academy.
 
Step Two: Contact
If self-service in NaviNet is unsuccessful, please use the claims investigation tool located in NaviNet. 
 
Step Three: Escalating
For claim escalation needs that you are unable to resolve through NaviNet or Customer Service Claims (CSC) Investigation, you can email this email box and include why NaviNet or Claims Investigation was not successful including the inquiry number from Customer Service.

FOR FEE SCHEDULES:
All fee schedules are available in NaviNet and will no longer be available via CSC, email or inquiry. 
If you are affiliated with a PHO, you must obtain the fee schedule from the PHO.
 
FOR TIMELY FILING:
Please submit your request via NaviNet using the Timely Filing form. 
 
Please remember – COB is not a member ID exception. Please complete the reconsideration form on NaviNet if another insurance was billed, recouped or denied the claim and you then submitted to BCBSNE.  
 
Provider Executives no longer address COBs submitted incorrectly on a timely filing form. 

Sign up for NaviNet

Registration is free; all you need is a Federal Tax ID. All participating Blue Cross and Blue Shield of Nebraska (BCBSNE) health care and dental providers can enroll for access. 
 
If your office is already using NaviNet, please contact your Security Officer to create a NaviNet account for you. If you do not have a NaviNet account, please visit Register.NaviNet.net to begin the registration process. 

Medical

Cardiovascular Disease: Documentation essentials for providers 

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in the U.S., making accurate diagnosis and treatment critical for patient outcomes. 1 For providers, comprehensive and precise documentation ensures a complete clinical picture and supports the accurate reflection of patient complexity in risk adjustment models, which is essential for quality care and reporting. 
 
Key Documentation Elements for Risk Adjustment:

  1. Document the specific type of CVD, such as: 2,3,4
    • Coronary artery disease (CAD): Specify if it is with or without angina and note the location of the vessel(s) affected.
    • Heart failure (HF): 3 Indicate the type (e.g., systolic, diastolic or combined) and acuity (acute, chronic or acute-on-chronic).
    • Acute Myocardial Infarction (AMI): 4 Include the type (e.g., STEMI or NSTEMI), affected coronary artery and whether the event is initial or subsequent. Specify the time frame for acute status (0-4 weeks) and document any complications. 
    • Arrhythmias: 2 Include specific arrhythmia types like atrial fibrillation or flutter, noting chronicity and any associated complications. 
  2. Clinical Status and Severity: Always describe the severity of the condition and its impact on the patient. 
  3. Comorbid Conditions and Risk Factors: 5 Since CVD often coexists with other chronic conditions, ensure documentation of comorbidities. Risk factors like smoking status, obesity and dyslipidemia should also be captured. 
  4. Clearly document the treatment and management plan, including:
    • Medications: Document compliance and any issues. 
    • Procedures: Specify interventions like stents, bypass grafting or valve replacements. 
    • Lifestyle modifications: Note recommendations for diet, exercise, cardiac rehabilitation, etc. 
    • For AMI: Document revascularization procedures (e.g., PCI, CABG) and follow-up management for post-AMI care. 
  5. Chronic conditions like CVD must be reviewed and documented annually, even if stable, to ensure an accurate clinical history. Update the patient’s status and any relevant changes in treatment or condition progression. 

Documentation Tips for Acute Myocardial Infarction (AMI)7
An AMI is considered acute during the first four weeks (28 days) following the onset of the event. After this period, if the patient is still receiving care for complications or sequelae of the infarction, the condition should be documented as subsequent myocardial infarction, a complication of the AMI (e.g., heart failure, cardiomyopathy) or considered an Old Myocardial Infarction. The following is required documentation for risk adjustment: 

  • The date of the AMI or indication that it occurred recently (within four weeks). 
  • Clearly specify any associated signs, symptoms or complications associated with the AMI.
  • Specify whether the AMI is a STEMI or NSTEMI.
  • Note the specific coronary artery affected (e.g., left anterior descending).
  • Provide details of interventions, such as thrombolytic therapy, PCI or CABG, and any outcomes. 
  • The AMI must be active within the data collection year and supported by documentation showing it was managed or treated during the encounter.
  • Correct ICD-10-CM coding is crucial. For example: 
    • STEMI: I21.0-I21.4
    • NSTEMI: I21.4
    • Old Myocardial Infarction: I25.2
  • If the patient has long-term conditions resulting from the AMI, these must be documented separately but do not document or code as an acute MI. 

Detailed documentation ensures that patients with CVD, including those with acute events like myocardial infarctions, receive appropriate care and that their health status is fully captured in risk adjustment models. By focusing on specificity, comorbidities and treatment plans, providers can enhance both patient outcomes and data accuracy. 

References: 
1CDC. (2024, April 29). Heart Disease Facts. Heart Disease. CDC Heart Disease
 
2American Heart Association. (2024, January 10). What is Cardiovascular Disease? www.heart.org; American Heart Association. What is Cardiovascular Disease
 
3American Heart Association. (2023). Types of heart failure. American Heart Association. Types of Heart Failure
 
4American Heart Association. (2017, March 31). Treatment of a Heart Attack. www.heart.org. Heart Attack Treatment
 
5World Health Organization. (2021, June 11). Cardiovascular Diseases (CVDs). World Health Organization. CVD Fact Sheet
 
6Rippe, J. M. (2019). Lifestyle Strategies for Risk Factor Reduction, Prevention, and Treatment of Cardiovascular Disease. American Journal of Lifestyle Medicine, 13(2), 204–212. Lifestyle Strategies for Risk Factor Reduction, Prevention, and Treatment of Cardiovascular Disease
 
7Optum360 EncoderPro.com - Login. (n.d.). www.encoderpro.com. https://www.encoderpro.com/epro/index.jsp

 

Medicare Advantage

Annual Wellness Visits and Comprehensive Physical Exams 

It is time to start planning for 2025 Annual Wellness Visits (AWV) and Comprehensive Physical Exams (CPE). Preventive and wellness care has multiple benefits for your practice and your patients. When implemented effectively, AWV/CPEs can benefit your practice by: 

  • Creating an opportunity to build a complete medical history for your entire patient panel
  • Strengthen your relationship and communication with your patients
  • Increase patient engagement
  • Increase quality metrics and close care gaps

BCBSNE covers the cost of your patient’s AWV and CPE once per calendar year. If additional tests and procedures (labs, EKG) are ordered or completed during the same visit, copays and deductibles may apply. 

Now is the time to start planning and scheduling your patients' AWV/CPE visits.

BCBSNE is committed to helping our providers build strong relationships with our members. If you are interested in assistance in building an efficient and effective AWV/CPE workflow within your clinic, please reach out to Erin Kuhr for more information.

Reminder - Medicare Advantage claims update

When submitting Medicare Advantage claims, Centers for Medicare & Medicaid (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 Nov. 26, 2024, we began 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. As a reminder, claim return letters are now available in Plan Documents on NaviNet.

Below are three common CMS standards that 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. 
  • Though not strictly enforced before, BCBSNE will now return or deny uncompliant claims.  

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.

Security Corner

Not-quite-real people

Newly dubbed gray identities are becoming increasingly popular for scammers who want to get free telehealth services, apply for remote work jobs and even complete loan applications.

A gray identity is an identity that isn’t completely fake, but it also is not an actual person — often it is an identity created with a little bit of stolen (real) consumer data, combined with some false information.

Watch for gray identities during your clinic’s new-patient and telehealth onboarding processes. Here are some things you can do to make sure that the digital person on the other end of the line is also an actual person:
  • Closely review new-patient documents; this is especially true for telehealth patients, who you won’t see in-person. Check for consistency across documents for name spelling, contact information, insurance ID, etc.
  • Keep track of whether a new patient frequently needs to reschedule telehealth services, especially if it is difficult to reach them through an “instant” communication method (like phone calls).
  • Be alert if a new patient requests that you update a significant portion of their patient information in comparison to what they (or another office) had just recently provided.

This newsletter serves as an amendment to your agreement as a contracting Blue Cross and Blue Shield of Nebraska health care provider and affects your contractual relationship with us.
NaviNet® is a health care provider portal providing services for Blue Cross and Blue Shield of Nebraska.
HEDIS, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance (NCQA).
Reveleer® is a healthcare SAAS platform that retrieves medical records for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.
Datavant Health is an independent company that collects medical records used for HEDIS® measurement quality data for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Associaton.
Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross Blue Shield Association. The Blue Cross Blue Shield Association licenses Blue Cross and Blue Shield of Nebraska to offer certain products and services under the Blue Cross® and Blue Shield® brand names within the state of Nebraska.

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