1. AAHAM

2. OUR PROVIDER NETWORKS

3. 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)

4. 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
NEtwork BLUE is our statewide network that is available to all employer groups.
Premier Select BlueChoice is our regional network supporting eastern Nebraska – the Omaha/Lincoln and surrounding communities in zip code areas of and 685

5. Select bluechoice
Select BlueChoice is tied to a three-tier product first offered in 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.
The change for 2017 was that BCBSNE was phasing out the 3-tier network and products.
Select BlueChoice Tier I and Premier Select BlueChoice providers are the same providers with same provider discount/allowable amounts applied.

6. Medicare advantage
Medicare Advantage is a new product available as of January 1, 2017.
Effective 1/1/17, BCBSNE is an authorized Medicare Advantage Organization offering two MA plans in the sections marked – Core HMO and Choice HMO-POS.
Please note that MA plans are Medicare replacement policies; therefore, it is not necessary to submit Medicare Advantage claims to Medicare. If you submit claims to Medicare in error, please do not include Medicare remittance advance when subsequently submitting to BCBSNE as doing so will delay the processing of the claim.

7. Medicare advantage Offered in these counties: Cass Dodge Douglas
Lancaster
Sarpy
Saunders
Even though the Medicare Advantage product was only sold to individuals in these six counties, we have contracted with some providers outside of this region of Nebraska. This means that all chiropractors in Nebraska are in-network with the Medicare Advantage product.

8. Medicare advantage – claim filing
Box 24J and 33a cannot be the same

9. MEDICARE ADVANTAGE – REMITTANCE ADVICE
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”.
BCBSNE MEDICARE ADVANTAGE PROVIDER SERVICE CENTER
BENEFITS AND ELIGIBILITY – OPTION 1
CLAIMS OR PROGRAM INFORMATION – OPTION 2

10. 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, 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.

11. Blueprint key healthcare providers

12. BluePrint Health card example

13. Chi employee Identification Card Example

14. Welcome
Insert introduction or agenda.
2 |

15. Contacting bcbsne

16. 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

17. NaviNet
NaviNet is our online secure provider portal to research eligibility and benefits, claims, RA

18. CUSTOMER SERVICE PROCESS CHANGE: Contact us
Effective March 1, 2017, all provider claim status questions must be submitted via a web inquiry at
If the IVR or NaviNet does not resolve your claims question, the next step is to submit an online request via nebraskablue.com/contact. Select the option under Provider for “Inquire about a Claim”.
Providers may still speak with a customer service rep for questions related to benefits and eligibility by calling the phone number. However, questions related to the status of a claim, appeal or reconsideration must be submitted online to us via the Contact Us form.
PROVIDERS MAY STILL CALL ON FEP MEMBER CLAIMS AND SPEAK WITH AN FEP CUSTOMER SERVICE REPRESENTATIVE. THAT PHONE NUMBER IS

19. IMPORTANT
Make sure to Indicate that a claim has been processed if appropriate to submit items that are under 30 days old.
If the claim has already processed but you still have a question on the claim, be sure to check the box next to “Has this claim already been processed”. Checking this box will allow your inquiry to be sent to BCBSNE.
We ask that you allow up to 5 business days for a response to your form.
If the response back from Customer Service does not answer your question, the next option is to contact our Provider Solutions Team.

20. Important phone numbers

21. 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.

23. preauthorizations

24. 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. procedures

25. 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.

26. Filing claims

27. 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.

28. 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.

29. 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.
In late summer of 2016, we sent a letter to all of our BCBSNE members advising of four items, the two items of relevance to this group being:
Radiology Quality Initiative – effective October 1, 2016 (the requirement for advanced imaging scans to be preauthorized)
Claim limit timely filing reminder - we included a reminder to our members of their responsibilities when providing information to providers and advised “that if the patient withholds information the provider needs to correctly submit a claim to us with 180 days of the date of service, the provider may not submit the claim and may bill the patient the full charges”.

30. 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

31. 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.

32. CODING REMINDER

33. CLAIM EXAMPLE: Blood Sugar Monitoring Billing

34. Subrogation and workers comp

35. 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.

36. Reconsideration versus appeal

37. RECONSIDERATIOn VERSUS APPEAL
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

38. RECONSIDERATIOn VERSUS 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

39. Claim edits

40. 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.

41. resources

42. NEBRASKABLUE.COM/PROVIDERS
Nebraskablue.com/roviders
The Update newsletter is a bi-monthly publication of news available to all provider types in the BCBSNE network. Beth Baer reviews these newsletters and will extrapolate the information that pertains to chiropractors. However, if you would like to receive notification once the Update newsletter has been updated, you can sign up at
The P&P manual is a helpful resource if you want to know the timely filing language, refund language – how far can BCBSNE go back and ask for a refund, more information on subrogation and so on.

43. Coming in 2018

44. 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.

45. 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 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.
Claims costs have continued to far outpace premiums for the Bronze and Catastrophic plans, and this, combined with the continued instability of the ACA and increasing uncertainty about what will replace it, led us to make this difficult decision.  We are projecting that by the end of 2017, the Bronze and Catastrophic individual plans will generate a loss of approximately $12 million.  That is in addition to the $150 million loss we previously experienced on the Individual ACA plans we sold on the federal Marketplace from 2014 through 2016.  Because of these losses, we stopped selling individual ACA plans on the federal Marketplace in 2017.
We have a shared responsibility to all our members to remain financially stable and secure.  That responsibility will be at risk if we continue to sustain losses in our ACA-compliant individual plans.  These two plans make up less than 2 percent of our overall business, yet we project that by the end of the year, they will have generated more than $80 million in claims in 2017.

46. Thank you for attending today’s presentation!
Questions?
Thank you for attending today’s presentation!