Medicare Advantage

We want to inform our Medicare Advantage (MA) providers of a recent issue involving claims that were incorrectly denied when the LT/RT modifier was billed but not required. The related claims edit was disabled as of Aug. 21, 2025.

No action is needed from providers at this time.

Please do not resubmit claims or escalate denials related to this issue — adjustments are already underway.

We appreciate your patience and continued partnership.

As of Jan. 1, 2025, all Medicare Advantage (MA) program operations transitioned fully in-house from Advantasure. The final step in this transition is the closure of all remaining 2024 claims. Claims with dates of service on or before Dec. 31, 2024 are no longer eligible for reconsideration or adjustment as of Jan. 1, 2026.

If you wish to appeal or dispute a 2024 claim, please submit your request as soon as possible to the contact information below:

Blue Cross and Blue Shield of Nebraska
PO Box 21831
Eagan, MN 55121
Fax: 1-877-482-9749

Please note that all clean MA claims must be submitted within 120 days of the date of service, or within the timeframe outlined in your provider agreement.

Beginning Jan. 1, 2026, no adjustments will be accepted for claims with 2024 dates of service — no exceptions. Any claims submitted after Dec. 31, 2025 will be rejected for timely filing. To avoid issues, please ensure all corrections are submitted as early as possible.

To ensure accurate billing and benefit coordination, please review the following guidance regarding Medicare Advantage (MA) refraction services under EyeMed and Blue Cross Blue Shield of Nebraska (BCBSNE).

Refraction Coverage

• EyeMed’s routine vision benefits include a comprehensive eye exam, which covers:
  
  • A health and wellness component
  • A refraction
• If the exam is deemed medical in nature, providers should bill the comprehensive eye exam to the member’s medical insurance.
• Important: EyeMed does not cover refraction-only claims. These will be denied if submitted separately.

Claim Submission Guidance

• Providers are not required to submit claims to both EyeMed and BCBSNE.
  
  • BCBSNE does not cover refraction under medical benefits
  • EyeMed denies refraction-only claims
• Submitting to both carriers does not result in coverage and may lead to unnecessary administrative effort.

To streamline administrative workflows, improve processing timeliness, and enhance overall care delivery efficiency, BCBSNE will transition to accepting preauthorization requests exclusively through our digital tools starting November 17, 2025. This change applies to medical preauthorization for our commercial lines of business. 

Participating providers are expected to use NaviNet, our provider portal, for their preauthorization submissions.

For out-of network and providers outside of Nebraska, a new online form will be available beginning November 1, 2025. 

Action Items:

• Register for NaviNet if you haven’t already
• Continue monitoring Happening Now and our Provider Bulletin for updates

As part of this transition, we will be retiring the commercial preauthorization fax lines on November 17, 2025:

• Medical (Outpatient): 1-800-255-2838 OR 402-392-4141
• Radiology: 1-800-991-5644 or 402-982-8644
• Commercial Pre-Cert (Inpatient): 800-821-4788/402-343-3444 and 1-866-422-5120

Note: If you submit faxes prior to the November 17 transition, you will receive messaging on your fax response notifying you of the upcoming change.

Fax lines remaining unchanged for medical records:

• Medical records for Appeals (submission of Appeals through the provider portal is preferred)
  
  • 888-492-4944
  • 402-548-4684
• Medical records for Commercial
  
  • 402-392-4111
  • 800-991-7389

Important: These fax lines are for medical records only. If preauthorization requests are sent to these numbers, they will not be processed, and providers will receive a faxed response indicating the request was misrouted.

Note: Medicare Advantage providers are encouraged to continue using the provider portal. The retiring fax lines apply only to commercial lines of business. Medicare Advantage fax lines are not affected and will remain in use as usual.

We appreciate your partnership as we move toward more efficient, digital-first solutions to support you and your patients.

For help getting started, visit the NaviNet FAQs in Provider Academy.

We’ve made improvements to the Provider Search functionality within the Preauthorization/Precertification workflow in NaviNet to support a more streamlined and accurate experience.

Key Updates:

• When submitting a Preauthorization/Precertification request for a member, the Quick Search will now only return in-network providers based on the member’s benefit plan.
  • Since member eligibility information is already entered, the system can determine network status and filter results accordingly.
  • We recommend searching by provider name whenever possible, as only the top 10 results will populate in Quick Search.
• If the provider does not appear in the Quick Search results, then that provider would be out-of-network for the members policy.
  
  • You may click the hourglass icon to the right of the search box to initiate an Advanced Search.
  • Non-participating (non-par) providers will only be displayed when using the Advanced Search feature.

These enhancements are designed to reduce search time, improve accuracy and ensure alignment with member-specific benefit plans.

Thank you for your continued partnership and attention to these updates.

Accurate billing for anesthesia services is essential for compliance and reimbursement, particularly when submitting data to under Centers for Medicare & Medicaid Services (CMS) guidelines.

CMS requires that anesthesia modifiers be listed first in the claim data sequence. These modifiers include:

• QZ – CRNA service without medical direction by a physician
  
• AA – Anesthesia services performed personally by an anesthesiologist
  
• QS – Monitored anesthesia care service

Following the anesthesia modifier, any physical status modifiers should be listed second. These typically include:

• P1 – A normal healthy patient
  
• P2 – A patient with mild systemic disease
  
• P3 – A patient with severe systemic disease
  
• (and others as applicable)

Proper sequencing ensures that claims are processed correctly and that providers are reimbursed appropriately. Failure to follow this order may result in claim rejections or delays.

For billing teams and providers, it's important to review internal systems and workflows to ensure that modifier sequencing aligns with CMS requirements.

While Medicare Advantage (MA) claims were previously allowed a 12-month timely filing window, contracts administered by BCBSNE include a 120-day filing requirement.

The provider procedure has been updated to accurately reflect this contractual requirement. Please ensure that all clean MA claims are submitted within 120 days of the date of service, or within the timeframe outlined in your provider agreement.

We are notifying you that claims submitted for Comprehensive Physical Exams (CPEs) billed with CPT codes 99381–99397 were erroneously denied for Medicare Advantage members due to a system configuration issue.

Issue Resolution:

The error has been identified and corrected. Impacted claims have been reprocessed and adjusted as of this week. Providers should begin seeing updated adjudication results in their remittance advice.

Next Steps for Providers:

No action is required for resubmission of affected claims.

If you believe a claim was missed or not adjusted correctly, please submit an Advanced Provider Inquiry.

We apologize for any inconvenience this may have caused and appreciate your continued partnership in delivering quality care to our members.

In order to obtain proper reimbursement for Medicare Advantage (MA) claims, please follow Original Medicare billing and coding guidelines. This information can be found at CMS.gov, searching for the appropriate topic.

We want to let you know about an upcoming change to our weekly batch claim payment schedule that will go into effect Nov. 1, 2025. We wanted to give you advance notice so you can analyze and prepare for the short-term impact this change will likely have on your organization.

Starting Nov. 1, each weekly batch claims payment will be comprised only of claims with receipt dates of at least 21 days. We are also shifting the weekly payment settlement date from Thursdays to Mondays. This change applies to all Blue Cross and Blue Shield of Nebraska (BCBSNE) lines of business, excluding the Federal Employee Program (FEP).  

We are making this change to reduce the need for post-payment corrections, which causes an administrative burden for providers and confusion for patients. In addition, we are subject to audits and validations to demonstrate accuracy for much of our government business, including Medicare Advantage and ACA plans.  Making this change ensures we have sufficient time to review and validate claims prior to payment.

This new payment cadence supports our ability to continue to provide you with timely payment in alignment with industry standards. Other carriers’ payment cycles range from 21-45 days.

Illustration of difference between current and new payment schedules

Short-term impact of payment cycle change

Because only claims with receipt dates of 21 days or more will be included in each weekly batch, it should be anticipated that for the first three weeks of the new schedule, your organization’s reimbursement amount will be lower than previous weeks, until the new cycle aligns with the adjusted cadence.

Improving the efficiency of our payments to you, as well as making interactions with the health care system less complicated and confusing for our members, are among our top priorities. If you have any questions about this upcoming change, please email Provider Partnership Director Dana Medeiros at Dana.Medeiros@NebraskaBlue.com with the subject line, Payment Schedule Change.

Beginning Aug. 1, 2025, BCBSNE MA claims for readmissions will follow the CMS guidelines denying the second admission. 

Please view the MA Readmission Quality Program procedure for more information. 

For BCBNE Medicare Advantage members with the YMA4 or Y2M4 prefix, timely filing denial appeals must be submitted using the Appeal option in NaviNet. Please be advise that paper submissions will not be reviewed.

This process is the same as the one currently used for commercial members.

At Blue Cross and Blue Shield of Nebraska, we are committed to working with our provider community as partners in health care.

Our new Reimagine Preauthorization page will keep you updated on how we're improving our preauthorization processes. Check back often to stay informed on the changes that matter most to you.

Together, we're reimagining the future of preauthorizations.

To ensure timely and accurate processing of Medicare Advantage (MA) dental claims submitted on behalf of members, please use the official 2025 Dental Reimbursement Form, available under the Provider MA Forms page on NebraskaBlue.

Kindly discontinue the use of outdated ADA claim forms. Utilizing the correct and current form helps streamline the reimbursement process and significantly improves turnaround times.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to transparency and keeping our providers informed. We are reaching out to notify you of significant changes and updates to the CMS RADV auditing process. Your support in providing medical records will be crucial as we navigate these changes.

Key Update:

On May 21, 2025, CMS announced a dramatic expansion of its RADV audit program that will affect all Medicare Advantage plans. This represents the most significant change to RADV auditing in the program's history.

What's Changed:

• Annual Audits: CMS will now audit all eligible MA contracts annually (previously ~60 contracts per year).
• Increased Sample Sizes: Audit sample sizes will increase from 35 to up to 200 member records per contract.
• Expedited Completion: CMS is expediting the completion of all audits for Payment Years 2018-2024 by early 2026.
• Expanded Workforce: The agency is expanding its medical coder workforce from 40 to 2,000 coders by September 2025.
• Enhanced Technology: Enhanced AI technology will be deployed to identify potentially unsupported diagnoses.

Although these audits are on the Medicare Advantage Organization, upon request, BCBSNE will need your support in providing medical records.

Thank you for your continued partnership and cooperation.