Provider Update November 2024

Medical

Recent updates to Policies 

• Canceled Procedure
• Confidentiality of Substance Use Disorder Patient Records Rule (42 CFR Part 2)
• Home Medical Equipment (HME)
• Readmission Quality Program

Revised Medical Policies

Effective Nov. 1, 2024:

• VIII.10 Standing Frames (Stander, Standing Device) 

Effective Dec. 1, 2024: 

• III.239 Lower Esophageal Myotomy for Treatment of Achalasia and Gastroparesis

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 us 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. 

Medicare Advantage

Recent updates to Medicare Advantage Policies

• MA Part B Utilization Management in the Absence of NCD or LCD Policy Number M.16
• MA Part B Utilization Management Review with NCD or LCD Policy Number M.17
• MA Part B Step Therapy for Outpatient Medications Policy Number M.18
• MA Part B Drug Prior Authorization List
• MA Prior Authorization and Precertification Requirements

New ID number for current BCBSNE MA members effective Jan. 1, 2025

BCBSNE is excited to inform you that all current BCBSNE Medicare Advantage members will receive a new member ID number, effective Jan. 1, 2025.

Key points to remember:

• New ID cards: Members could begin to receive new ID cards in the mail by early October.
• Prefix for new ID cards: To help identify which ID card is the new one for Jan. 1, 2025, the prefix will be different.
  • YMA4 will be the new prefix for the HMO product instead of YMAN.
  • Y2M4 will be the new prefix for the PPO product instead of Y2MN.
• Effective date: These new ID numbers will not be valid until Jan. 1, 2025.
• Usage: Please note that the new ID numbers should be used for services on or after Jan. 1, 2025.

If you receive a new ID number from a current BCBSNE Medicare Advantage member, please remember that it will only be effective for dates of service from Jan. 1, 2025 onwards.

This information was posted on the MA Happening Now page on Oct. 1, 2024. Thank you for your attention to this important update!

MA split-year claim submission

Non-Nebraska outpatient, professional claims and CAH swing bed

For outpatient, professional and CAH swing bed claims with charges incurred during different years, the charges must be submitted on separate claims. This requirement will be the same each year end for split-year claims.  

Claims for non-Nebraska members that are not split will reject back to the provider upon submission. 

For example:

If dates of service are from Dec. 15, 2024, to Jan. 15, 2025:

• Submit charges incurred from Dec. 15, 2024, to Dec. 31, 2024, on one claim
• Submit charges incurred from Jan. 1, 2025, to Jan. 15, 2025, on a separate claim

Claims submitted with charges incurred during both years on the same claim will be rejected back to the provider to split the claim. 

Institutional Inpatient Claims
For inpatient* institutional claims, it is no longer required to split the entire claim for non-Nebraska members.

*Inpatient includes acute care hospital, psychiatric hospital, rehabilitation hospital, skilled nursing and swing-bed (excluding CAH swing bed).

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).

Medicare Advantage Preauthorization update for Medical Specialty Drugs webinar

• The policies and procedures for this new program.
• What medical benefit drugs will require prior approval.
• How to obtain access to the Prime website.
• How to complete prior authorization requests using easy-to-use online tools from Prime.

Medicare Advantage Preauthorization update for Musculoskeletal (MSK) and Interventional Pain Management (IPM) webinar

BCBSNE has expanded its partnership with Evolent (formerly National Imaging Associates, Inc) to include BCBSNE Medicare Advantage members for the Musculoskeletal (MSK) and Interventional Pain Management (IPM) authorization programs that have existed for commercial members since 2015. Evolent’s MSK and IPM Solutions programs are intended to help providers effectively deliver quality patient care.

Evolent is an independent company providing MSK and IPM solution programs for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.

Effective Jan. 1, 2025, MSK and IPM services will require prior authorization through Evolent prior to being rendered in an inpatient or outpatient setting (MSK) or outpatient facility/office setting (IPM). Providers may begin contacting Evolent on Jan. 1, 2025, to seek prior authorization for procedures scheduled on or after Jan. 1, 2025. This prior authorization management program applies to your BCBSNE Medicare Advantage members. 

Evolent uses clinical criteria based on nationally recognized guidelines to promote evidence-based practices. 

The Evolent program will apply to all specialties for the following non-emergent inpatient and outpatient MSK surgeries: 

Lumbar

• Lumbar Microdiscectomy
• Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy and Foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
• Lumbar Artificial Disc Replacement – Single and Multiple Levels

Cervical

• Cervical Anterior Decompression with Fusion – Single and Multiple Levels 
• Cervical Posterior Decompression with Fusion – Single and Multiple Levels
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement – Single and Multiple Levels
• Cervical Anterior Decompression (without fusion)  

The Evolent program will apply to all specialties for the following outpatient IPM procedures: 

• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)

Prior authorization requests for MSK and IPM services can be submitted to Evolent:

• Via Evolent provider portal at RadMD.com 
• Via telephone at 1-800-424-4956. Staff is available Monday - Friday from 7 a.m. to 7 p.m. CST.

RadMD offers providers the ability to: 

• Request prior authorization and verify authorization status. 
• Upload required clinical documentation and view submitted files. 
• Access clinical guidelines, checklists and additional provider resources and tools.
• Identify the dedicated Evolent Provider Solutions Manager to use as a direct point-of-contact for any issues or questions.

BCBSNE Medicare Advantage approvals issued before Jan. 1, 2025, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. For services/treatment that did not require an authorization prior to Jan. 1, 2025, an authorization may be required from Evolent for service/treatment dates on and after Jan. 1, 2025. 
 
Any BCBSNE Medicare Advantage prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the service has met Evolent’s medical necessity criteria. 
 
BCBSNE Medicare Advantage is proud to be your health care partner. If you frequently request MSK and/or IPM services and are new to this process, please register for a training session.

Telephone:

+1-305-224-1968 US
+1-646-931-3860 US

Meeting ID for Tuesday, Nov. 19, 2024, at 8 a.m. CST: ID# 910 3096 1772
Meeting ID for Thursday, Nov. 21, 2024, at 12 p.m. CST: ID# 979 5575 1234
Meeting ID for Tuesday, Dec. 10, 2024, at 12 p.m. CST: ID# 941 1187 2952
Meeting ID for Thursday, Dec. 12, 2024, at 8 a.m. CST: ID# 995 2090 7746
 
If you have questions, please contact BCBSNE Medicare Advantage Provider Services Department at 1-888-505-2022. If you have questions about Evolent MSK or IPM programs, please email RadMDSupport@Evolent.com or call 1-800-327-0641.

We look forward to offering you this program and hope it will enhance your experience with MSK and IPM authorizations.

Security Corner

Where to start

1. Mandate the use of MFA. Ensure everyone uses multi-factor authentication (MFA) to access key systems, especially email, and on your website and portal logins for your patients. 
2. Train your staff. Everyone should have the ability to recognize social engineering attempts, like phishing, as well as the motivation to avoid and report all kinds of security risks.
3. Update your software. Regularly update the devices and applications you’re using. Many attacks succeed because the victim is running old, vulnerable operating systems and software.