Provider Update March 2025

Medicare Advantage

Reminder: Medicare Advantage reimbursement

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

Reminder: MA auto approval for Skilled Nursing Facility admissions

Effective Jan. 1, 2025, BCBSNE began the new process to automatically approve the first seven days in a Skilled Nursing Facility for all MA PAR providers.

Notification of Admission is required within 72 hours of admission.

Notification of Admission:

• This can be provided via NaviNet by submitting an authorization and 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. 

Qualified Medicare Beneficiary (QMB) program

Per Center for Medicare & Medical Services (CMS) guidelines, the Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries. 

Federal law forbids Medicare providers and suppliers, including pharmacies, from billing people in the QMB program for Medicare cost sharing. Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or Part B deductibles, coinsurance or copays for any Medicare-covered items and services. You must not charge a beneficiary enrolled as a QMB for Medicare cost sharing amounts even if their QMB benefit is from a different state than the state where they get care. QMBs can’t elect to pay Medicare deductibles, coinsurance and copayments.

More information on this CMS program is available at CMS.gov.  

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. 

Medical

Updated TriWest information for BCBSNE providers

TriWest is currently experiencing system issues, which may affect the availability of information for providers. This includes technical issues with the referral/authorization tool.

Providers should use the following TriWest resources:

• TRICARE West Region Referral Waiver Approval Letter
• Fax: 866-852-1893 (for same-day, urgent referrals, fax detailed information)
• TriWest Provider Resources document

BCBSNE can assist with the following:

• Adding Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page above
• Adding New group Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page above
• Adding Existing group Individual Providers to the TRICARE Roster: Submit changes through CAQH Provider Data Portal to have the provider’s information updated

Credentialing Variances for TRICARE Network in Nebraska:

• Licensure Disciplinary Actions: Providers with actions on their state licenses cannot be offered participation in the TRICARE network
• Board Certification: PAs, CRNAs, and CNMs must be board certified to be offered participation in the TRICARE network
• Provisional providers-excluded from TRICARE network.

Accreditation Requirements:

• Birthing Centers: Must be accredited by TJC, AAAJHC, CABC, or AABC and licensed according to state and local laws
• Substance Use Disorder Rehab: Must be accredited by TJC, CARF, or COA
• Intensive Outpatient Programs (IOP): Must be accredited by TJC, CARF, or COA
• Psychiatric Residential Treatment Facilities: Must be accredited by TJC, CARF, or COA
• Residential Treatment Centers (RTC): Must be accredited by TJC, CARF, or COA

Note: These requirements differ from our regular requirements, as we only verify accreditation but do not require it.

Exciting updates for our provider community: Preauthorization changes

We are thrilled to announce several significant changes that will benefit our provider community and enhance patient care. These changes do not apply to our Medicare Advantage plans.

CPAP Authorization changes

As announced in January and in our February Provider Bulletin, effective Jan. 10, 2025, BCBSNE no longer requires preauthorization for the following CPAP device codes:

• E0601
• E0561
• E0562

This change streamlines processes and reduces administrative burdens, allowing you to focus more on patient care. Additionally, BCBSNE will reprocess claims received for dates of service beginning Jan. 10, 2025. Any previously denied claims will be automatically reprocessed, eliminating the need for reconsideration requests.

Radiology/Imaging Policy updates

Lung cancer screening
On Feb. 18, 2025, we announced on Happening Now that, effective Feb. 15, 2025, policy IV.81 was revised to improve access to essential health services. Procedure Code 71271 no longer requires preauthorization or medical review. This update simplifies the process, reduces administrative tasks and supports early detection and better health outcomes for your patients. The InterQual criteria for commercial plans have been updated to reflect this change.

Myocardial perfusion imaging
On Feb. 28, 2025, we announced on Happening Now that, starting March 15, 2025, policy IV.81 has been further revised. The following CPT codes for myocardial perfusion imaging no longer require preauthorization or medical review for our commercial plans:

• 78451
• 78452
• 78453

These updates aim to streamline access to essential health services, reduce administrative burdens and enhance patient care.

We are committed to continuously improving our services and policies to better support your practice. If you have any questions or need further assistance, please contact our provider support team. Thank you for your continued partnership and dedication to providing excellent care.

Audiology testing 

In January on Happening Now and in our February issue of Provider Bulletin, we advised that BCBSNE member contracts exclude audiological function tests except for limited circumstances.   

Effective Feb. 1, 2025, dispensing fees will no longer be considered content to the hearing aid purchase and, if billed, will no longer deny as provider contractual write-off.  

BCBSNE pilots new well-being program with employees

BCBSNE has launched Amplify Health, a new pilot well-being program for its employees. The goal of Amplify Health is to improve health outcomes and lower costs for BCBSNE employees and their families.

The program is designed to equip employees with actionable data about their health, including their current and future health risk, diagnosed chronic conditions, reminders about preventive screenings and more. BCBSNE employees who elect our medical insurance coverage will receive a customized health profile based on their claims history. In 2025, employees are incentivized to complete an annual preventive exam and biometric screening.

As a provider partner, we wanted to make you aware of this new program. Pilot participants may bring a copy of their health profile to their appointments to discuss with their health care providers. In the future, BCBSNE will explore expanding this program to additional members.

Together, we can make a difference in the health and well-being of our members, your patients.

BCBSNE introduces Enhanced E-Consultation Policy effective May 1, 2025

• Utilize procedure codes 99446-99449, 99451 or G0546-G0550 when billing for medical consultations.
• Avoid billing for e-consultation services if a face-to-face encounter with the patient has occurred within the last 14 days.

• Use procedure codes 99452 or G0551.
• These services can only be reported once every 14 days.

• Apply the Place of Service code that indicates your location when providing the service.
• Note that e-consultation services with Place of Service codes 02 or 10 will be denied.

Dental

Join us at the 2025 NDA Annual Session

BCBSNE is thrilled to connect with our provider community at the 2025 NDA Annual Session on Friday, April 11 in Lincoln. Your presence is highly valued, and we look forward to seeing you there!

Risk Adjustment

Diabetes: Documentation essentials for providers

Diabetes is a chronic condition affecting how the body processes sugar (glucose). It can lead to severe complications such as neuropathy, nephropathy, retinopathy, cardiovascular disease and more. Proper documentation of diabetes and its associated manifestations is critical for accurate risk adjustment, as it ensures that patient severity and resource needs are fully captured.  
 
Key documentation elements for risk adjustment:

• Specify the type of diabetes
  • Type 1, type 2 or other specific types (e.g., gestational, secondary to another condition or drug-induced). 
• Document complications or manifestations
  • Document complications such as diabetic neuropathy or peripheral vascular disease. 
• Link diabetes to its complications
  • Use explicit language to connect the diabetes diagnosis with related complications (e.g., “diabetic nephropathy” rather than listing them separately).
• Specify disease control:
  • Document if the diabetes is controlled, uncontrolled, etc. 
• Detail coexisting conditions:
  • Clearly record other comorbidities or factors impacting diabetes management (e.g., obesity, hypertension, hyperlipidemia). 
• Use accurate and specific ICD-10-CM codes:
  • Example: Use ICD-10-CM codes such as E11.22, type 2 diabetes with chronic kidney disease, stage specified.
• Include treatment details:
  • Document medication use (e.g., insulin or oral agents), lifestyle interventions or other management strategies.  
• Include social and behavioral factors:
  • Mention any noncompliance or barriers to effective disease management, as applicable.  

Documentation tips for diabetes

The following is required documentation for risk adjustment: 

• Clearly identify the type of diabetes.
• Explicitly connect diabetes to its complications (e.g., “diabetic neuropathy” or “diabetic retinopathy”).
• Specify whether diabetes is controlled, uncontrolled or in remission. 
• Review laboratory results and use the results along with medication lists and treatment plans to support the diagnosis. 
• Note insulin or oral medications, dietary modifications, and other interventions. 
• Identify and document coexisting conditions such as obesity, hypertension or hyperlipidemia. 
• Ensure codes reflect the most specific diagnosis and complications. 
• Replace vague terms like “diabetes with complications” with detailed descriptions of specific manifestations. 
• Document social, behavioral or economic factors impacting diabetes management (e.g., noncompliance). 

Accurate, complete and specific documentation not only supports risk adjustment but also enhances the quality of care for diabetic patients. 

Providers are responsible for documenting and coding all conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. 
 
For any questions or requests for additional documentation and coding education, please contact us at RiskAdjustment@NebraskaBlue.com.
 
References: 
Centers for Disease Control and Prevention. (2024, May 15). Diabetes Basics. www.cdc.gov. Diabetes
 
Optum360 EncoderPro.com - Login. (n.d.). www.encoderpro.com. https://www.encoderpro.com/epro/index.jsp

Security Corner

Calls from “patients”

Be mindful of potentially fake patient calls, a new trend targeting medical offices nationwide. Someone might pretend to be a patient or family member, asking for urgent details like appointment times or medical records. They could sound convincing, using real names or emotional stories to push you into sharing info, potentially posing a risk to patient privacy or safety.

Always verify before you share. If someone calls asking for sensitive details, don’t give anything out right away. Try to verify the caller’s identity, or politely say you’ll call them back using the phone number on file—not one that the caller provides. This simple step can stop cybercriminals in their tracks.

Unsure of your office’s verification-of-identity process? Contact your supervisor or your Privacy Officer to get up to speed; generally speaking, HIPAA requires that Covered Entities have a process in-place to verify someone’s identity before sharing PHI (45 CFR 164.514(h)).