1. American Association of Health Care Administration Management Conference
October 19, 2016

2. Agenda Claims Filing Edits – Verscend Reconsiderations Versus Appeals
Timely Filing Reminder
Guidelines For Medicare Secondary and Preauthorization's
Clear Coverage: Radiology Program
Clear Coverage: Day One Precertification
Identification Card Examples
MedPolicy Blue Tool
Exiting The Market Place
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3. Claim Filing Edits – Verscend
Verscend is 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.
Newsletter articles in Updates dated September & November 2015 provide additional information. Please see the articles at
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4. Reconsideration Versus Appeal
A Reconsideration is a request from a provider for BCBSNE to review a claim using additional information not previously provided- use this for claim of Modifier 25 or 59.
Claims edit information
Medical Records
Subrogation or worker’s compensation
Coordination of benefits
An Invoice for Pricing Review
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5. Reconsideration Versus Appeal
Appeals
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
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6. Timely Filing Reminder
It is important to verify the timely filing limitation of the medical policy of the member.
Some groups may have a nonstandard filing time limit. Members timely filing can vary from the providers agreement. The members filing limitation will supersede the provider agreement.
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7. Guidelines For Medicare Secondary and Pre-authorizations
Effective July 1, 2016
BCBSNE will no longer require our providers to do preauthorization's on BCBSNE members who have Medicare as their primary carrier.
Providers can submit preauthorization's for review but a claim will not be denied for lack of preauthorization.
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8. Clear Coverage: Radiology Program
Effective October 1st, 2016
Services in conjunction Emergency room visit, observation and inpatient stays do not need a preauthorization.
In the first week there were over 1000 preauthorization's done through Clear Coverage
If you order MRI, MRA, CT/CTA, PET or Nuclear Cardiology services please make sure someone in your office has an account set up.
If you have not set up an account with Clear Coverage you can contact Provider Solutions for assistance option 4, option 1 or option 4, then option 1.
Or to create your user account.
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9. Pre-Certification on Day 1
Effective January 1, 2017 BCBSNE requires precertification for all acute inpatient and observation admissions for BCBSNE members
Guidelines
Planned admission – on or before admission date
Unplanned admissions should occur on the first business day following admission
Does not apply to:
Members with Medicare Supplement coverage
Members for whom BCBSNE is secondary
Hospital stays for labor and delivery (48-96 hour admissions).
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10. Clear Coverage: Day One Precertification
Precertification is required to receive benefits for inpatient or observation care provided to BCBSNE members.
If no preauthorization is obtained care will be denied as provider liability without opportunity to balance bill the impacted BCBSNE member.
Precertification requests are submitted utilizing the Clear Coverage tool. To create your user account visit:
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11. Clear Coverage: Day One Precertification
Save the Date: Day One Precertification Review Webinars
Webinars about how to use the electronic precertification tool are scheduled for 12 to 1 p.m. (CST) on the following dates:
Nov. 10 and 17
Dec. 6 and 14
If you have any questions about the information in this letter, please contact your Provider Relationship Manager (PRM).
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12. Identification Card Examples
BCBSNE Provider Networks  
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13. MedPolicy Blue
The MedPolicy Blue tool offers a streamlined method to review our medical policies and confirm what services need to be preauthorized.
Providers will be able to submit their pre-authorization requests within each respective policy, saving time on the steps associated with the pre-authorization process.
Customer Service is no longer a resource for determining if preauthorization is required.
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14. MedPolicy Blue
Within the Medical Policies section the following information is available:
Medical Policy Updates are posted on our website.
Services, Procedures & Medical Policies Requiring Prior Authorization – a quick resource guide.
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15. Exiting the Public Market Place
Effective January 1, 2017, BCBSNE is eliminating the individual Gold, Silver, Bronze and Catastrophic plans sold through the public Marketplace ( as well as the Gold and Silver plans sold on the private ACA Marketplace (
Customers currently covered under one of these plans have been notified to purchase new coverage for next year.
BCBSNE will continue to offer our Bronze and Catastrophic individual plans for sale on the private Marketplace, and customers currently covered under these plans are unaffected by our decision to exit the public Marketplace.
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16. Why We Exited the Public Market Place
Serious issues with the ACA as it currently stands are making the Marketplace more and more unstable, which is increasing costs and decreasing competition and consumer choice.
BCBSNE has a responsibility to all our members to remain stable and secure. BCBSNE does not want to have continued multi-million dollar losses by our ACA individual plans to begin to negatively impact rates for customers covered under other BCBSNE lines of business.
The decisions we make are by Nebraskans and for Nebraskans.
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17. Any Questions? Thank you
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