Medicare Advantage

Blue Cross and Blue Shield of Nebraska (BCBSNE) would like to remind providers of the following guidelines regarding MA prior authorizations (PA):

• Observation Level of Care: No prior authorization (PA) submission is required for Observation level of care.
• Inpatient Admissions: Prior authorization (PA) is required for inpatient admissions.
• Upgrading from Observation to Inpatient: If a patient is upgraded from Observation to an inpatient level of care, please submit a PA request via NaviNet. Ensure that the observation dates are included to bundle the observation days with the Diagnosis-Related Group (DRG) for claims and billing purposes.

We are pleased to announce that on July 15, we will be hosting a Western Nebraska Provider Summit in Kearney, Nebraska. This event is designed to provide valuable insights and updates on Blue Cross and Blue Shield of Nebraska's (BCBSNE) commercial and Medicare Advantage lines of business.

Our focus is on our provider partners west of Omaha, and we highly value your input to tailor the summit to meet your needs. Please take a moment to complete the survey below by May 1 to let us know your preferences and any specific topics you would like to see covered.

Input Survey

Please note that this event will focus exclusively on medical topics. However, we are planning to host a behavioral health and dental forum in late 2025 or early 2026.

We look forward to your participation and to making this forum a valuable experience for all attendees. Please keep an eye on the Happening Now in May for more information on the event and how to register.

Blue Cross and Blue Shield of Nebraska (BCBSNE) recently identified an issue with the processing of certain Medicare Advantage (MA) claims that have frequency limits, such as mammograms. Here are the key points:

• Issue Identified: When both facility and professional claims were submitted for services with frequency limits, only one of the two claims was allowed. The claim processed last was denied with the message: "This procedure exceeds the maximum frequency allowed per Medicare Advantage guidelines."
• Correction Implemented: The issue has been identified and corrected. All claims processed after March 25, 2025, are now being handled correctly.
• Reprocessing Affected Claims: BCBSNE is identifying and automatically reprocessing the affected claims that were processed incorrectly between January 1, 2025, and March 24, 2025.
• No Action Required: There is no need to resubmit these affected claims. Please allow 30-45 days for the reprocessing of these claims.

The authorization templates for MA Inpatient Acute Medical, Inpatient Acute Surgical, and Inpatient Observation have been consolidated into a new and improved MA Inpatient Acute Care template. This streamlined template enables providers to select from various treatment types, including Observation, Medical (inpatient), Surgical (inpatient), and Transplant (inpatient). 

In cases where an authorization is initially reviewed and approved with an Observation treatment type, and the provider wishes to submit an extension that transitions the patient from observation to an acute level of care, the provider should select one of the applicable non-observation treatment types at the additional extension line level.

BCBSNE Provider Executives are available to support providers with the following:

• Timely Filing Reviews submitted via NaviNet
• Escalated Claims Inquiries
• Provider Agreement Inquiries
• Provider Data Changes

Effective May 1, 2025, you will be able to submit your inquiries to the Provider Executive team via the new Advanced Provider Inquiries form on NaviNet. This form will collect all the required information needed to address your questions, thereby streamlining the process and reducing the number of communications.

Please note that this new form does not replace the existing Claims Investigation process available on NaviNet. You will still need to submit a Claims Investigation request before contacting the Provider Executive team via the Advanced Provider Inquiries form.

As of May 1, 2025, the ProviderExecs@NebraskaBlue.com email account will be decommissioned, and you will no longer be able to send requests to this email address.

For additional updates, including an eLearning module, please refer to Happening Now as the effective date approaches.

Billing MA claims accurately is crucial for providers to ensure timely reimbursement and compliance with regulations. Currently, we are seeing MA claims with a 114 TOB being billed where the member was admitted in 2024 but the statement dates on the 114 TOB claim are all in 2025.

To address this issue, BCBSNE will soon introduce new edits to reject specific TOB/REV Code combinations or TOB/Status Code combinations. Here’s a guide to help providers navigate these changes and maintain consistency in billing practices.

Understanding TOB Codes

Type of Bill (TOB) codes are essential for indicating the nature of a claim. For Medicare billing, certain TOB codes are valid, while others are restricted. Here are the key points to remember:

• TOB 112: This code is valid for Medicare billing. Hospitals should use TOB 112 for initial interim claims, indicating that a patient is expected to remain in the facility for an extended period.
• TOB 117: After the initial interim claim has been submitted, TOB 117 should be used for continuing and final claims. This ensures that the billing reflects the ongoing care and eventual discharge of the patient.

Avoiding Invalid TOB Codes

Certain TOB codes are not valid for Medicare PPS claims. Providers should be aware of the following restrictions:

• TOB codes 0XX3 and 0XX4: These codes are not valid on Medicare PPS claims. Providers must resubmit claims with the appropriate TOB 0XX7.
• Interim continuing and final claims: Instead of using TOB 0113 or 0114, providers should submit claims using TOB 0117. This involves submitting an adjustment to cancel the original interim bill and rebilling the stay from the admission date through the discharge date.

Consistency in Billing Rules

By following the guidelines outlined above, providers can ensure their claims are processed correctly and avoid rejections due to invalid TOB codes.

Conclusion

Adhering to the proper billing practices for Medicare claims is essential for providers to maintain compliance and ensure accurate reimbursement. By understanding and applying the correct TOB codes, providers can navigate the edits and continue to deliver quality care without disruptions in billing.

For any further questions or clarifications, providers should reach out to their billing support team or consult the latest Medicare billing guidelines.

Our Medicare pricing tool utilizes the NPPES data registry to link the Medicare Number/CCN with the NPI data listed in the registry. If there is a discrepancy between the data in the registry and what is submitted on the claim, the claims may be delayed or potentially returned. Therefore, it is crucial for providers to ensure accurate updates to the NPPES and to deactivate outdated information.

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.

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.