Medicare Advantage

As you may know, BCBSNE recently implemented a medical pharmacy prior authorization program with the Prime Therapeutics Medical Pharmacy Solutions team (Prime). You can find detailed information about this program on the Provider Academy page.

In effort to encourage providers to utilize their provider portal, GatewayPA.com the Prime team will begin making outreach calls to encourage provider offices. GatewayPA offers an efficient way to request and view medical pharmacy prior authorizations managed by Prime. Please note that these calls are not sales calls, but rather an effort to enhance your experience with Prime for their medical pharmacy prior authorization program.

Please contact the Prime MPS Provider Relations department with any questions at ProviderInquiry@PrimeTherapeutics.com.

Ambulatory Surgical Centers (ASCs) must utilize the appropriate ASC billing taxonomy for MA claims to ensure accurate claim adjudication. This practice aids in accurately identifying the facility type and ensures that MA claims are processed correctly.

When submitting claims for services rendered in 2025, please use the updated MA ID numbers with the following prefixes:

• YMA4 will replace YMAN as the prefix for the HMO product.
• Y2M4 will replace Y2MN as the prefix for the PPO product.

This change will help reduce the likelihood of returned or denied claims.

Medicare Advantage (MA) home health prior-authorizations differ slightly from the commercial line of business. Please review the below MA home health prior-authorization process that Home Health Agencies (HHA) must follow.

Authorization Decisions

• We will review and make a decision for up to 48 units in the first 30 days, any additional units requested within the first 30 days will be reviewed by our medical directors.
• Upon additional clinical documentation prior to the 31^st day, we will review and make a decision up to 48 additional units for days 31-60. Any additional units requested within the second 30-day period will be reviewed by our medical directors.
• A new authorization and the below requirements will need to be submitted after the 60-day expiration date of the initial authorization.

Submission Requirements:

• Submit in Units (15 min increments) for all services, not visits. This differs from commercial as Medicare Advantage codes are billed in units and not visits.

Eligibility:

•  Patients must be homebound and require skilled nursing care or therapy services.
• A physician must certify the need for home health services and establish a plan of care.

Plan of Care:

• The plan of care must be individualized, detailing the specific services and goals for the patient.
• It must be reviewed and signed by a physician or an allowed practitioner.    
• For episodes/periods with starts of care beginning January 1, 2011 and later, in accordance with §30.5.1.1 (Medicare Benefit Policy Manual, a face-to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services, and was performed by a physician or non-physician practitioner

Initial and Comprehensive Assessments:

• HHAs must conduct an initial assessment within 48 hours of referral or return home from an inpatient facility.
• A comprehensive assessment must be completed within five days of the start of care (SOC) date.

OASIS Data Submission:

• HHAs are required to submit OASIS (Outcome and Assessment Information Set) data for review and quality reporting purposes.

BCBSNE conducts settlements on hospital claims for BCBSNE Medicare Advantage (MA) members. This applies to in network Critical Access Hospitals and Rural Health Clinic providers. Below are a few FAQ reminders on the MA interim reimbursement letters.

How do I submit my MA rate letter provided by CMS?

• Please email the CMS MA rate letter to ProvidereExecs@NebraskaBlue.com.
• Please include the information in the format below:
• Provider TIN
• Provider Medicare ID# (Provider NPI)
• Provider Method I or II

When do I need to submit these requests?

• Rate letters must be submitted within 60 days of being published by the MAC.

For more information on this procedure please see MA Critical Access Hospital Cost Settlement for In-Network Providers.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is offering two exciting incentive opportunities to our participating Medicare Advantage (MA) providers for the role they play in caring for our MA members.

BCBSNE hosted a virtual town hall on Jan. 31, 2025, outlining the two program offerings below for clinics with MA member attribution of 20 or more. 

• Provider Excellence Program (PEP) 
  • Incentives for performance in Medicare Advantage quality measures
  • Additional inventive for high performing entities achieving a high performance for certain quality measures
  • Upside only agreement

• Chronic Condition Revalidation Incentive (CCRI) 
  • Incentive for managing members with specified chronic conditions
  • Upside only agreement The PDF of the Value-Based Incentive Program presentation is available on our Provider Academy. 

The PDF of the Value-Based Incentive Program presentation is available on our Provider Academy. 

Identity theft is a growing concern in healthcare, where sensitive personal and medical information is handled daily. Implementing robust identity theft precautions is crucial to safeguard patient information and maintain trust. One effective practice is verifying photo IDs, which plays a significant role in preventing identity theft and ensuring accurate patient identification.

Benefits of Photo ID Verification

• Accurate Patient Identification: Ensures the person receiving care is the patient on record, reducing medical errors.
• Enhanced Security: Adds an extra layer of security, making it harder for individuals to use stolen identities.
• Improved Trust and Confidence: Patients feel more secure knowing their information is protected, building trust in the provider-patient relationship.

By incorporating these measures into your daily operations, you can significantly reduce the risk of identity theft and enhance the overall patient experience.

We are excited to share an important update regarding the verification of coverage for our members. With our recent enhancements, you can now accurately verify coverage using just the member’s name and date of birth. This means you no longer need the prefix and Card ID number to confirm active membership with our BCBSNE members.

We appreciate your attention to detail in ensuring our members receive the best service possible. Thank you for your continued dedication and support. 

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. 

Effective Jan. 1, 2025, BCBSNE began the new process to automatically approve the first 7 days in a Skilled Nursing Facility (SNF) for all MA PAR providers.

Notification of Admission is required within 72 hours of admission.

Notification of Admission:

•  Can be provided via NaviNet by submitting an authorization, allowing access to the authorization if a continued stay review is needed.
• If continued stay review is needed, you can access the authorization to conduct your review via NaviNet, but only if the initial review was submitted via NaviNet.

Alternative Notification Methods:

• Fax to the UM fax line: 1-866-422-5120
• Call the UM phone line: 1-877-399-1671

Concurrent Authorization Review:

• Required to certify additional days.
• Ensures timely issuance of Notice of Medicare Non-Coverage to the facility and the member. 
• If faxing the medical records, please fax the documents by noon the day they are due to maintain timeliness of the review.

BCBSNE is committed to the health and well-being of our members and communities we serve.

The MA Provider Service phone line will be closed for department meetings as they are for commercial. Below are the upcoming hours that the MA Provider Service phone line will be closed.

Feb. 25. 2025 - 9:45 a.m. to 12:30 p.m.

Every Wednesday from 9 a.m. to 10:30 a.m.

We recently communicated a change in the management of certain drugs under the medical benefit for Medicare Advantage (MA) members. The prior authorization requests can be submitted via web exclusively through GatewayPa.com. The MA Part B drug request form has been retired and you will no longer be able to submit these prior authorizations via fax.

Thank you for your continued support in ensuring our members receive high-quality and clinically appropriate care.

We are delighted to offer our Medicare Advantage members the ability to fill prescriptions for 100 days in 2025.    

Filling maintenance medications for 100 days at a time is not only convenient but also helps patients stay adherent to their treatment plans and take their medications as prescribed by their healthcare provider.

Medicare Advantage dental plans are reimbursement policies only. Members pay the full amount to the provider and then they will submit a claim for reimbursement.

In order to assist your patients please consider providing them with documentation that includes your TIN and NPI numbers. This will make filing and reimbursement easier for them.

Reimbursement amounts vary by plan:

• Core HMO is $1,950.00
• Connect PPO is $1,500.00
• Access PPO is $2,050.00
• Secure PPO is $2,050.00

All plans have no deductible, and covered services must be performed by a licensed dental provider. Please contact the member to confirm which dental plan they have.

Blue Cross and Blue Shield of Nebraska (BCBSNE) has discovered Medicare Advantage (MA) 27x transactions are only giving specialist copay information. The PCP copay information is missing, leading providers to request that MA members pay the specialist copay in error.  We are working on this issue but do not currently have an ETA. For BCBSNE MA PCP providers, please do not charge a copay to members based on the 271 eligibility response transactions until this is resolved.  

Updated EOPs will be sent once a fix is in place. Continue to watch the MA Happening Now for updates.

For MA 2024-2025 outpatient, professional and CAH swing bed claims with charges incurred during different years, the charges must be submitted on separate claims.  

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. 

When submitting Medicare Advantage claims, CMS standards must be followed to prevent unnecessary returns and processing delays. Effective June 4, 2024, with the CMS edits in place you will see non-Nebraska MA claims process more appropriately.

Beginning November 26, 2024, we will begin adjusting claims appropriately prior to June 2024, in accordance with the MA adjustment language. Providers can expect to see these adjustments reflected throughout December 2024 and January 2025.

Please do not submit Reconsideration Requests for claims you believe did not pay correctly. We will be running reports to determine if adjustments or recoupments are needed. Reminder, claim return letters are now available in Plan Documents on NaviNet^®.

Below are three common CMS standards that would need to be followed to avoid claims being returned or denied. 

DME NU & RR Modifiers

• Claims that are billing supply codes with NU modifier, and they do not require an NU modifier, will be denied.
• If billed without BP and BR modifiers that go with certain rentals, they will be denied as well.  

Federally Qualified Health Centers (FQHC) and Rural Health Claims

• Per CMS guidelines Medicare Advantage FQHC and Rural health claims will need to be billed on a UB04 instead of on a CMS 1500 form.
• We were not enforcing before and are now and will be returning or denying claims as appropriate. 

Ambulance for MA only

• Per CMS guidelines, ground mileage totaling up to 100 covered miles must be reported to the nearest tenth of a mile.  In addition, all air ambulance mileage must be reported as fractional units to the nearest tenth of a mile.   When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile.
  • Professional Electronic – When submitting fractional units, the Provider needs to submit the same fractional units in the Ambulance Mileage field on the 837P AND the units field.
  • Professional Paper (CMS-1500) – When submitting fractional units, the Provider needs to submit the fractional units in the units field.
  • Institutional Electronic – When submitting fractional units, the Provider needs to submit the fractional unit in the units field. There is not a separate Ambulance Mileage field on the 837I for Institutional.
  • Institutional Paper (UB-04) – Providers should continue to submit whole units as decimals are not allowed on the UB in the units field.
• Claims will be returned if not submitted correctly.