Network Participation

Overview  
Blue Cross and Blue Shield of Nebraska (BCBSNE) will give select provider types an opportunity to apply for participation in the Medicare Advantage network. Network providers provide care to BCBSNE Medicare Advantage members, and we reimburse them for covered services at the agreed upon payment rate. Network providers must sign formal agreements with BCBSNE, to participate in the Medicare Advantage networks. By signing the agreement, the provider agrees to bill us for covered services provided to BCBSNE Medicare Advantage members, accept our reimbursement as full payment minus any member required cost sharing, and receive payment directly from BCBSNE.  

Qualifications and Requirements  
To be included in BCBSNE Medicare Advantage network, providers must:

• Have a national provider identifier used to identify the provider when submitting electronic transactions to BCBSNE (in accordance with HIPAA requirements) or to submit paper claims to BCBSNE 
• Meet all applicable licensure requirements in the state of Nebraska and meet BCBSNE credentialing requirements pertaining to licensure  
• Provide services to a BCBSNE member within the scope of their licensure or certification and in a manner consistent with professionally recognized standards of care  
• Provide services that are covered by our plan and that are medically necessary by Medicare definitions  
• Meet applicable Medicare approval or certification requirements  
• 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 
• Sign formal agreements with BCBSNE  
• Agree to bill us for covered services provided to BCBSNE Medicare Advantage members  
• Accept our reimbursement as full payment less any member cost sharing  
• Receive payment directly from BCBSNE  
• Not be on the U.S. Department of Health and Human Services Office of Inspector General excluded and sanctioned provider lists  
• Not be a Federal health care provider, such as a Veterans’ Administration provider, except when providing emergency care  
• Comply with all applicable Medicare and other applicable Federal health care program laws, regulations, and program instructions, including laws protecting patient privacy rights and HIPAA that apply to covered services furnished to members  
• Agree to cooperate with BCBSNE to resolve any BCBSNE Medicare Advantage member grievance involving the provider within the time frame required under federal law 
• For providers who are hospitals, home health agencies, skilled nursing facilities, long-term acute care hospitals or comprehensive outpatient rehabilitation facilities, provide applicable member appeal notices 
• Not charge the member in excess of cost sharing under any condition, including in the event of plan bankruptcy  
• Provide certain special services to members only if approved by Medicare to provide such services (e.g., transplants, VAD distribution therapy, carotid stinting, bariatric surgery, PET scans for oncology, or lung volume reduction). The list of special services will be automatically updated as determined by CMS.  
• Be in good standing with BCBSNE and meet and maintain all BCBSNE credentialing requirements for network inclusion. Examples of being in good standing are:
  • Unrestricted license to practice  
  • No license limitations  
  • Not on prepayment utilization review, not in the performance monitoring program or not de-participated from the Traditional program  
  • Not denied or disaffiliated from the TRUST program within a two-year period of application to BCBSNE Medicare Advantage  
  • No Medicare or Medicaid exclusion, sanction or debarment  
  • Not opting out of Medicare  
• Agree to accept all BCBSNE Medicare Advantage members unless practice is closed to all new patients (commercial or Medicare)