Network Information and Affiliation

Overview 
Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage includes a network of health care providers consisting of primary care physicians, specialists, hospitals and other health care providers who have agreed to provide services to BCBSNE Medicare Advantage members. The BCBSNE Medicare Advantage plan focuses on delivering cost-effective and quality patient care. Network providers agree to accept BCBSNE reimbursement as payment in full for covered services (minus any member required cost sharing). Members with BCBSNE Medicare Advantage coverage receive services from a select network of providers. 

Network Sharing 
For the HMO and PPO plans the provider just needs to accept the Medicare Advantage plan (BlueCard^® participation is not required).  

If you are a contracted Medicare Advantage provider for BCBSNE and you see Medicare Advantage members from other Blue plans, these members will be extended the same contractual access to care and you will be reimbursed in accordance with the rate for your Medicare Advantage contract. These members will receive in-network benefits in accordance with their member contract. 

Effective July 1, 2014, the Blue Cross Blue Shield Association issued a mandate to all Association members, which requires all participating providers to be responsible for obtaining pre-service reviews for inpatient facility services provided to Medicare Advantage members from other states. Keep the following guidelines in mind: 

• Obtain pre-service reviews prior to admission for inpatient facility services when such a review is required under the member’s plan.
• Out-of-state members will be held harmless if a pre-service review is required and not performed prior to admission for inpatient facility services. You cannot bill or collect from a member for covered services where you failed to perform pre-service review as required.  
• Specified timeframes for pre-service review may apply. These include: 48 hours to notify the host plan of a change in the pre-service review and 72 hours in the case of an emergency or urgent care notification.

Affiliation
Professional and Facility Enrollment  
Information on how to enroll in the Medicare Advantage Network is available in the Credentialing section of NebraskaBlue.com/Credentialing.  

Eligible Practitioners 
Practitioners eligible for affiliation in the BCBSNE Medicare Advantage are: 

• Medical Doctors
• Doctors of Osteopathy  
• Doctors of Podiatric Medicine  
• Doctors of Dental Surgery (oral surgeons only)  
• Doctors of Chiropractic Medicine  
• Anesthesia Assistants  
• Audiologists  
• Certified Nurse Practitioners  
• Certified Nurse Midwives  
• Certified Registered Nurse Anesthetists  
• Independent Physical Therapists  
• Occupational Therapists  
• Optometrists  
• Hearing aid dealers  
• Fully licensed psychologists  
• Clinical licensed master’s social worker  
• Ambulance providers  
• Independent speech language pathologists  
• Clinical nurse specialist  
• Physician assistant  
• Licensed Mental Health Practitioner  
• Licensed Independent Mental Health Practitioner

Facility Affiliation 
Facilities eligible for affiliation in the BCBSNE Medicare Advantage network are:  

• Ambulatory surgical facilities (freestanding only) 
• End stage renal disease facilities (hemodialysis centers) 
• Federally qualified health centers  
• Home health care facilities  
• Hospitals  
• Long-term acute care hospitals  
• Outpatient physical therapy facilities  
• Rural health clinics  
• Skilled nursing facilities  

Affiliation requirements include:  

Facility  
Facilities must meet certain requirements to participate in the BCBSNE Medicare Advantage network. These requirements are available in the applications which can be found in the provider enrollment section of NebraskaBlue.com/Credentialing.

Practitioner  
Practitioners (except ambulance) who request affiliation in the BCBSNE Medicare Advantage Network must meet specific network requirements and complete an online application on the Council for Affordable Quality Health Care ProView Data source (CAQH) website. Typically, up to five years of history are reviewed during the initial credentialing process. We use the same review process to credential new applicants and to recredential network practitioners.  

• BCBSNE registered — must be or become registered with BCBSNE and have an active provider record. To become registered, go to NebraskaBlue.com/Credentialing.
• Fully licensed — must be fully licensed and free of any current disciplinary actions of suspension, revocation, surrender, limitation or probation. A provider who has any of these disciplinary actions imposed because of a criminal conviction related to payment or provision of health care will be restricted from applying to the network for a period of two years following the date the license restriction is lifted.  
• Malpractice coverage — must have and maintain current malpractice coverage of $100,000 per occurrence, and $300,000 annual aggregate. The coverage must protect the provider from all liability, whether a claim is filed against the individual provider or jointly with a hospital. Liability insurance must cover all practice locations unless the provider is directly employed by a hospital and practices exclusively at that hospital.  
• Professional certification bodies — non-physician providers must be in good standing with designated professional certification bodies applicable to their area of expertise.  
• Government sanctions — must be free of any exclusions or sanctions from Medicare and Medicaid.  
• Opt out — must not have opted out of participation in the Medicare program under §1802 (b) of the Social Security Act, unless providing emergency or urgently needed services.  
• Prepayment utilization review — an applicant who is currently in or has a significant history in the BCBSNE prepayment utilization review program will be denied affiliation with the BCBSNE Medicare Advantage network.  
• BCBSNE departicipation — an applicant with a current or significant history of formal departicipation action by BCBSNE will not be accepted in the BCBSNE Medicare Advantage.  
• Malpractice case history — must be reported with supporting details. These include the number of malpractice cases against the applicant that have been filed, adjudicated or settled within the five years prior to the application date. We review all cases against established screening criteria and may deny the application.  
• Substance abuse or chemical dependency — current use or recent history of illegal drug use or substance abuse or dependence will result in a denied application. New applicants with history of chemical dependence or substance abuse must:  
  • Provide proof of treatment  
  • Be substance-free during the 24-month period before application 
  • Attest that they have no current chemical dependence and are currently free of all illegal chemicals  
• Additional considerations — we may use other information in credentialing and recredentialing review and decision-making, such as:  
  • Data Bank (National Practitioner – Healthcare Integrity and Protection) findings  
  • No history of conduct that threatens patient safety or adversely affects BCBSNE's business interests 

Affiliated Provider Agreement  
As an affiliated provider, you agree to (but not limited to): 

• Meet our re-credentialing requirements every three years (includes facilities)  
• Meet and maintain board certification requirements (when applicable) 
• Abide by the BCBSNE Medicare Advantage Network agreement, policies and procedures (includes facilities)  
• Bill only for professional services personally provided by the BCBSNE Medicare Advantage Network provider. (This specifically prohibits billing for services provided by any subcontractor, or other provider, including a partner in a group practice.)  
• Note: The only exception is when a physician personally supervises a provider who cannot bill BCBSNE directly. Provide complete care within the BCBSNE Medicare Advantage provider’s specialty and do not systematically refer or “share” the care of patients  
• Provide safe, medically necessary and cost-effective care (includes facilities)  
• Maintain a current and accurate CAQH ProView record — update the CAQH ProView minimally once every 120 days and re-attest to the completeness and accuracy of the information.

Disaffiliation 
The BCBSNE Medicare Advantage Provider Agreement can be terminated by BCBSNE or an affiliated provider, in accordance with the terms of the Agreement. When the agreement is terminated, the provider is no longer affiliated with the BCBSNE Medicare Advantage network. We call this activity “disaffiliation.”  

There are two types of disaffiliations:  

• Voluntary— initiated by the provider at any time, except during the initial term of the Agreement, with 60 days written notice to BCBSNE or as otherwise provided in the Agreement 
• Involuntary— initiated by BCBSNE in accordance with the terms of the Agreement and applicable internal policies. Depending on the reason(s) for this type of disaffiliation, you may be able to re-apply for affiliation two years after the disaffiliation date.