Billing Members

Collect coinsurance and or copayments at time of service 
Providers should collect the applicable coinsurance and/or copayments, also known as the members cost share, from the member at the time of the service when possible. After collecting these amounts, bill your local Blue plan for covered services. 

Balance billing is not allowed 
You may only collect applicable cost sharing from Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage members for covered services and may not otherwise charge or bill them. 

Refund overbilled members 
If you collect more from a member than the applicable cost sharing, you must refund the difference. Medicare Advantage members are to be reimbursed within 30 days of recognizing the error. 

Coordination of benefits 
If a member has primary coverage with another plan, submit a claim for payment to that plan first. The amount we will pay depends on the amount paid by the primary plan. We follow all Medicare secondary payer laws. 

Non covered services and referrals for non covered services  
Sometimes you and your patient may decide that a service, treatment or item is the best course of care, even though it isn’t covered by BCBSNE Medicare Advantage plans or may be supplied by another provider or practitioner. 

You are responsible for determining which items, services or treatments are covered. If you  believe that a service, item or treatment won’t be covered, you must tell the member before the service or treatment is performed or item obtained. If the member acknowledges that the item,  service or treatment won’t be covered by Medicare Advantage and agrees that they will be solely responsible for paying you, you may perform and bill the member for the non–covered service, treatment or item. When the member covers an expense for an item, service or treatment, the rendering provider will submit a claim to the plan for a post service organization determination, using the appropriate modifier when applicable. 

If you provide an item, treatment or service that is not covered and have not provided the patient with prior notice that the item, treatment or service is not (or may not be) covered by the plan, you may not bill the patient for such non covered items, treatments or services. 

If a provider believes an item, service or Part B drug may not be covered, the provider must advise the enrollee to request prior approval from the MA plan or the provider may request prior approval on the enrollee’s behalf. - Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.