Provider Update September 2024

Medical

Recent updates to Policies 

• Mental Health Provider Levels GP-P-015

Revised Medical Policies

The following medical policies had changes effective Sept. 1, 2024:

 

• V.58 Oncology: Algorithmic Testing
• VIII.7 Adjustable Cranial Orthoses for Plagiocephaly and Craniosynostosis
• III.239 Lower Esophageal Myotomy for Treatment of Achalasia

BCBSNE Provider Procedures Name Update

Our Policies & Procedures page has been renamed to BCBSNE Provider Procedures. The searchable format to access these procedures has not changed, but the name has been updated to be more inclusive of the information you are able to search for.

Diagnostic related group (DRG) audits impacted by Change Healthcare event

Payment integrity activity DRG Audit was being completed by Change Healthcare. As they are no longer providing this service, Blue Cross and Blue Shield of Nebraska (BCBSNE) has not received DRG audit services since Feb. 1, 2024. We have had to pause our activities to implement with a new vendor. The new vendor has been chosen and implementation is underway. Please watch Provider Updates for more information as it becomes available.

Dental

NaviNet^®: Available to dentists

NaviNet^® is available to dentists to check claim status, eligibility and benefits and fee schedules. The online portal is offered at no cost to our providers. It’s easy to use and gives you a dashboard to access helpful information for your BCBSNE patients. If you have not tried NaviNet, we encourage you to do so.

Sign up for NaviNet here!

ID cards and SOBs for BCBSNE members are also available in NaviNet. To view BCBSNE member ID cards and SOB summaries, choose the Eligibility and Benefits workflow and then enter the information for the member you wish to search. NOTE: The BCBSNE member ID does not need to be included to search.

Watch Happening Now as we continue to enhance NaviNet throughout 2024.

Medicare Advantage

BCBSNE MA Auto Approval for SNF Admissions

BCBSNE is pleased to announce beginning Jan. 1, 2025, we will waive authorizations the first seven days in a Skilled Nursing Facility (SNF) for all MA PAR providers. Notification of Admission is required within 72 hours of admission. Concurrent authorization review is required to certify additional days, thus allowing us to issue the Notice of Medicare Non-Coverage timely to the facility and the member.
  
If a SNF admission goes beyond seven days; authorization will be required on day eight and after. BCBSNE is committed to the health and well-being of our members and communities we serve.

Medicare Advantage Provider Procedure Updates

Currently the Medicare Advantage (MA) Procedures are housed as PDF documents on our Medicare Advantage Policies page. As we begin moving our support of our MA program fully in house, we will also be updating how the MA Provider Procedures are delivered in 2025.

Effective Jan. 1, 2025, you will be able to use the BCBSNE Provider Procedures search tool to locate MA procedures. When searching for a MA procedure with a keyword in this tool, you can filter the policies by selecting the Medicare Advantage tag on the left-hand side of the search results.

For more information on the BCBNE Provider Procedures you can review the eLearning under the Provider Academy.

Family of Codes on MA Preauthorization Letters

When a decision is made on an MA preauthorization, the decision letters will only include the codes that were submitted on the authorization. The family of codes will not be included on these MA letters.

Medicare Advantage Happening Now Articles will be Moving

In the upcoming months we will be implementing changes on our Medicare Advantage page. The first of these exciting changes is the transition of our MA Happening Now articles. All Happening Now information specific to MA will now be located on the MA page. 

Now you will be able to view all the articles regarding MA in one place. Be sure to keep an eye on the Medicare Advantage page for future updates, this will be your "one stop" page for MA as we move this business in house.

What is the Medicare Prescription Payment Plan or M3P? 

The Medicare Prescription Payment Plan, also referred to as M3P, is a new payment option starting in 2025 for Medicare members that works with their current drug coverage and can help them manage their prescription drug costs by spreading them across monthly payments that vary throughout the year (January – December).

This payment option might help them manage their expenses, but it doesn’t save them money or lower their drug costs. All Medicare members are eligible to participate in this payment option, regardless of income level, and all Medicare drug plans and Medicare health plans with drug coverage must offer this payment option.

If your Medicare patients have any questions, they can contact us at 855-457-1349 or visit Medicare.NebraskaBlue.com to find out more about the new Medicare Prescription Payment Plan.

Medicare Advantage Access Standards

BCBSNE establishes provider access standards in accordance with CMS regulations for BCBSNE Medicare Advantage members. The following standards apply to BCBSNE Medicare Advantage Primary Care and Behavioral Health in-network providers for BCBSNE Medicare Advantage. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP).

CMS requires the hours of operation of practitioners are convenient for and do not discriminate against members. Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours service, or recorded message directing members to a physician for after-hours care instruction. Recorded messages instructing members to obtain treatment via an emergency room for conditions that are not life threatening is not acceptable. 

Provider Type	Appointment Type
Primary Care Provider General Practice Family Practice   Internal Medicine Pediatric Medicine Obstetrics and Gynecology practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
Behavioral Health Provider Psychology Psychiatry  Mental Health and Substance Abuse practitioners	Routine and Preventive care must be provided within 30 business days of patient request. Non-Urgent care requiring medical attention must be provided within seven business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
After-Hours Access to Care
CMS requires that the hours of operation of its practitioners are convenient for and do not discriminate against members.     Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours telephone number (to a practitioner’s home or other relevant location), pager or answering service or a recorded message directing members to a physician for after-hours care instruction.     Note: Recorded messages instructing members to obtain treatment via emergency room for conditions that are not life threatening is not acceptable. In addition, primary care physicians must provide appropriate backup for absences.

Security Corner

Security Corner: EFT Fraud

BCBSNE has become aware of increased attempts by cyber criminals to gain provider bank account information.

This is done by cyber criminals contacting the provider via phone or email, posing as BCBSNE and convincing the provider to “confirm” their electronic banking (EFT) information.

If you receive an unsolicited email or call, claiming to be from us, advising you to “confirm” or “update” your EFT details, do not provide any information, and contact your BCBSNE Provider Executive immediately.