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AAHAM. OUR PROVIDER NETWORKS. Network blue . NEtwork BLUE is available throughout the state of Nebraska Includes 95% of Nebraska providers and all non-governmental , acute care hospitals. UniNet (CHI Health) providers included Two-tier product (in-network or out-of-network ).
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Network blue NEtwork BLUE is available throughout the state of Nebraska • Includes 95% of Nebraska providersand all non-governmental, acute care hospitals. • UniNet (CHI Health) providers included • Two-tier product (in-network or out-of-network)
Premier select bluechoice The Premier Select BlueChoice network is a regional network available in Omaha, Lincoln and surrounding communities. • CHI Health providers are not included • Two-tier product
Select bluechoice Select BlueChoice is tied to a three-tier product first offered in 2012. There are two in-network tiers of benefits and one out-of-network tier. Starting with January 2017 effective dates, three-tier products will no longer be offered. For renewals beginning with a January 1, 2017 effective date, we will renew groups on a two-tier product. Exception to this rule: hospital employer groups – we will continue to allow custom three-tier network and designs. As they renew, groups currently on the Select BlueChoice product will be moved to the PREMIER Select BlueChoice product.
Medicare advantage Medicare Advantage is a new product available as of January 1, 2017.
Medicare advantage Offered in these counties: • Cass • Dodge • Douglas • Lancaster • Sarpy • Saunders
MEDICARE ADVANTAGE – REMITTANCE ADVICE BCBSNE MEDICARE ADVANTAGE PROVIDER SERVICE CENTER 888 505-2022 BENEFITS AND ELIGIBILITY – OPTION 1 CLAIMS OR PROGRAM INFORMATION – OPTION 2 Remittance advices and payments for Medicare Advantage claims are issued separately from other BCBSNE business. Therefore, you will need to work with the BCBSNE Medicare Advantage Provider Service Center for this product for any questions or issues. There are three ways to identify a Medicare Advantage payment: The remittance advice will state “SAPPHIRE EDGE, INCL SUB BCBSNE”. The member’s policy number begins with “YMAN”. If it is an EFT payment, the related check number will begin with a “5”. Please note that all paper checks will begin with a “4”.
Blueprint health Blue Cross and Blue Shield of Nebraska is pleased to offer Blueprint Health. This new regional network is available to fully insured and self-funded large groups starting January 1, 2018. It features CHI Health providers and facilities in Nebraska and contiguous counties in Iowa, as well as other providers. Blueprint Health is for groups that are headquartered in the Omaha/Lincoln area and surrounding communities in ZIP codes 680, 681, 683, 684 and 685, as well as Adams, Buffalo, Hall, Kearney and Phelps counties.
Welcome Insert introduction or agenda. 2 |
Options for obtaining claim status and member benefits Self-service options: • The IVR (automated phone information) • NaviNet (online provider portal) • Remittance Advice (remits or EOBs) • Return Letters • Electronic Claims Rejection report from clearinghouse • www.nebraskablue.com/providers
CUSTOMER SERVICE PROCESS CHANGE: Contact us Effective March 1, 2017, all provider claim status questions must be submitted via a web inquiry at www.nebraskablue.com/contact.
IMPORTANT Make sure to Indicate that a claim has been processed if appropriate to submit items that are under 30 days old.
Provider solutions team If you need to reach out to this team, please make sure that you tell them of your prior attempts in seeking out resolution to your questions. Provider Solutions may ask if you have checked NaviNet and requested assistance from Customer Service through the “Contact Us” form. If you have an inquiry number from your contact with Customer Service, please share that information with Provider Solutions.
Authorizations - radiology Beginning October 1, 2016, certain radiology services must be preauthorized. The following services require preauthorization: • Computed Tomography (CT/ CTA) • Magnetic Resonance Imaging (MRI/MRA) • Nuclear Cardiology • Positron Emission Tomography (PET) • If services are not preauthorized, the claim from the servicing provider will be denied indicating provider liability. • Additional information can be found in the Policy and Procedure Manual. https://www.nebraskablue.com/providers/policies-and-procedures
Authorizations - radiology RADIOLOGY: NAVINET SINGLE SIGN-ON FOR CLEAR COVERAGE To simplify access to Clear Coverage, Blue Cross and Blue Shield of Nebraska has moved to a single sign on for the Outpatient Radiology Preauthorization process. Effective May 1, providers can access the Clear Coverage Outpatient Radiology Preauthorization tool using NaviNet. Clear Coverage has been enhanced to also allow servicing facilities to view preauthorizations.
TIMELY FILING • Provider is responsible for clean claims, adjustments or revisions to timely filed claims. • Filing timeframe specified according to agreement can vary. • 120 days • 180 days • Master Group Application or Summary Plan Description • The time limit is set forth from the date of service. • FEP follows the same timely filing requirements.
Provider compliance requirements Providers are contractually responsible to file claims, adjustments or revisions in a timely manner. If a claim for a covered person is not filed originally within the timeframe and in compliance with BCBSNE Policies and Procedures no benefits will be paid. Provider agrees that no payment will be pursued from the covered person for any service not submitted in compliance with the timely filing terms of their agreement. Adjustments or revisions to timely filed claims must be made within 12 or 18 months from the last payment.
Timely filing – member liability It is the member’s responsibility to present a current identification card or provide verification of coverage with the correct insurance information in order for the provider to file a clean claim. When a member withholds information preventing a provider from filing a timely claim, do not file the claim for the patient/member because the claim will deny as provider liability. Be sure to document your engagement with the member while attempting to obtain current insurance information. The member is responsible and should be billed for the charges when withholding information needed to file the claim after the provider has made written attempts to obtain the insurance information.
Clean Claim Definition BCBSNE requires providers to submit clean claims for all services provided promptly and in the format requested regardless if there are other sources of payment or reimbursement A clean claim is for health care services provided to a covered person by a provider on a UB04 or CMS 1500 (or successor form) or an electronic form in compliance with BSBSNE Policies and Procedures. All required fields must be completed with all information necessary to adjudicate the claim. A claim that rejects electronically or is returned to the provider with an “action needed letter” is not considered a clean claim
Rejected – Returned Claims Do not send a claim with “corrected claim” or “replacement claim” written or typed on the claim itself, as it will be returned to be resubmitted correctly. If a claim submission is rejected due to incorrect or invalid information, it is the provider responsibility to make the necessary corrections and resubmit the claim within the timely filing period. Claim rejected electronically or returned is not considered a clean claim and not accepted as proof of timely filing.
subrogation If a covered benefit involves claims that are a result of an accident or illness caused by a third party, you must file a claim including accident information to BCBSNE. We will provide benefits according to the member’s contract and supply payment to the provider of service pursuant to our agreement. Our Subrogation Department will begin the necessary procedures to recover paid amounts from the covered person or third party payer, which will not exceed the amount we paid in benefits. When more than one insurer is responsible for payment, providers must file claims for all services to both insurers. Claims to BCBSNE must be filed within the timely filing guidelines or claims will be denied as provider write-off.
RECONSIDERATIOn VERSUS APPEAL Reconsideration A Reconsideration is a request from a provider for BCBSNE to review a claim using additional information not previously provided. • Claims edit information • Medical Records • Subrogation or worker’s compensation • Coordination of benefits • An invoice for pricing review
RECONSIDERATIOn VERSUS APPEAL Appeal An Appeal is a request from a provider for BCBSNE to review a claim with a disposition that the member or provider disagrees with based on the information presented. • Medical policy denials • Medical necessity denials • Experimental denials • Investigational denials
CLAIM FILING EDITS - VERSCEND • Since March 1, 2016, Verscend has been reviewing claims for BCBSNE following the AMA guidelines for coding with modifiers 25 and 59. • If the claim or a line item from the claim is denied for the usage of a modifier and you have supporting documentation of correct usage of the modifier please submit as a RECONSIDERATION and include Medical Records. • Checking the box next to “APPEAL” for these claims denials will result in a further delay in processing the request form. Claims will be returned to the provider for clarification.
NEBRASKABLUE.COM/PROVIDERS Nebraskablue.com/roviders
NEW PREFIXES NEW PREFIXES FOR MEMBER ID CARDS COMING IN 2018 BCBSNE member ID numbers currently begin with a three-character alpha prefix. Beginning in early 2018, we will introduce alpha-numeric prefixes to our member ID cards.
PRODUCTS: ACA-COMPLAINT INDIVIDUAL PLANS Effective January 1, 2018, BCBSNE will stop selling our ACA-compliant Bronze and Catastrophic individual plans. Customers enrolled in these two plans will need to enroll in a new plan with another carrier for 2018. We have notified the 12,500 impacted members. • Prefix: YEH Unaffected by this decision are the approximately 20,000 members covered by our pre-ACA individual plans.
Questions? Thank you for attending today’s presentation!
