December 2025 Quarterly Provider Insights

Quarterly Provider Insights shares information to our provider community in the third month of each quarter.

Quarterly Provider Insights will provide information regarding a company message, news and announcements, educational topics and miscellaneous updates.

Provider Message

Spotlight on our Special Investigation Unit (SIU) and Provider Audit department

2026 Provider Audit Work Plan   

Blue Cross Blue Shield of North Dakota (BCBSND) established the Special Investigations Unit (SIU) department to ensure that claims paid by BCBSND are free from coding or billing errors and services provided were medically appropriate, necessary and delivered in accordance with the member's benefit plan, accepted medical practice standards and BCBSND policies. These processes ensure fair and equitable coding and billing practices as well as protect our members. The SIU and Provider Audit department is committed to protecting our members’ interest through education, deterrence, detection, investigation and resolution of health care fraud, waste and abuse (FWA).

As part of the 2026 Provider Audit Work Plan, BCBSND is informing providers that the Special Investigation Unit (SIU) and Provider Audit department are building the 2026 Provider Audit work Plan.   

The Provider Audit Work Plan at this time will include scheduled audits to review:  

• Non-emergency Medical Transportation (NEMT)   
• Modifier AF  
• Laboratory Services 
• Psychotherapy 
• Treatment Modalities 

The Work Plan is subject to change based on emerging risks. These audits will not impact all providers.  Per the SIU and Provider Audit process detailed in the BCBSND Provider Manual, claims identified as potentially at risk of inappropriate submission, coding or payment are selected for additional review. Medical records and any additional information, if required, will be requested from the provider or facility with an identified due date.   

Questions?

For additional information on the SIU and Provider Audit department and process, please see the BCBSND Provider Manual and Medicaid Expansion Provider Manual Special Investigations Unit sections. 

News and Announcements

ND Caring Foundation: Together, We Make a Difference: Celebrating Our Year of Community Impact

As we look back on the past year, our hearts are full of gratitude and pride. The BCBSND Caring Foundation 2025 Community Impact Report is more than a summary of numbers; it’s a celebration of the compassion, generosity and spirit that each of them brings to our organization and our communities.

Our Shared Purpose

Every day, our employees show what it means to care. Whether it’s volunteering their time, sharing their talents, or giving from the heart, their help builds a healthier, more hopeful North Dakota. Because of them:

• Over 750,000 lives were touched
• More than 4,000 hours were volunteered
• 100+ nonprofits received support
• More than $1 million was donated to causes that matter

These aren’t just statistics — they are stories of neighbors helped, families supported, and futures brightened.

The Power of Giving

Our Blue & You volunteer program is a testament to their kindness. Half of our employees volunteered this year, strengthening bonds with local organizations and making a real difference where it’s needed most. From their Dollars for Doers request we provided $29,000 to help others, and countless acts of kindness have rippled through our communities.

Our Impact

For more than 35 years, the BCBSND Caring Foundation has supported sustainable and innovative efforts by collaborating with organizations across North Dakota. To learn more about our Caring Foundation visit https://www.bcbsnd.com/caring-foundation.

We will continue to lift each other up, celebrate successes, and look forward to another year of making a difference — together. 

Educational

On the Radar: Appeals Documentation

Documentation Matters:
Blue Cross Blue Shield of North Dakota (BCBSND) is seeing more appeals submitted without enough documentation, which leads to delays and denials for both Commercial and Medicaid Expansion plans. Proper documentation is crucial for a smooth review process and timely decisions.

Tips for Providers

• Always include supporting documentation with your appeal. Incomplete documentation means your appeal will be returned, and you’ll need to resubmit within the required time limits. The original submission date won’t count if documentation was missing.

Submission Time Limits

• Commercial Appeals:
  • Submit within 180 days of the adverse determination or notification from BCBSND (for both pre- and post-service appeals).
• Medicaid Expansion Appeals:
  • Submit within 60 days of the adverse determination or notification from BCBSND (for both pre- and post-service appeals).
• Send only the necessary documentation to support your appeal. Too much unrelated information can also cause delays.
• Check BCBSND Medical Policies for specific documentation requirements, especially for medical necessity. For example, ambulance providers must keep trip sheets and documents if multiple individuals are transported.

Questions?

• See the appeals and documentation sections in the Provider Manual and Medicaid Expansion Provider Manual.
• Contact Provider Service Center:
  • Commercial: 800-368-2312
  • Medicaid Expansion: 833-777-5779

Did you know: Telehealth is Here to Stay

Telehealth lets providers use secure tech (like video or audio) to treat patients remotely. It’s got to follow state and federal laws, and providers still need to meet the same care standards as they would in person. 

There are two different types of Telehealth

Synchronous (Real-Time)

• Originating/Distant Site: Patient is at a clinic (originating site), provider is elsewhere (distant site). Home or community settings don’t count as originating sites.
• Digital E-Visits: Member starts the visit via a provider’s portal. It’s low complexity and doesn’t usually need follow-up.
• Virtual Check-Ins: Quick chats to decide if a full visit is needed.
• Audiovisual Communication: Real-time video between patient and provider.

Asynchronous (Store-and-Forward)

• Remote Monitoring: Devices at home track things like blood pressure or weight.
• Inter-professional Referrals: Providers consult each other online without the patient present.
• Consultations: Specialist gives advice based on another provider’s request.
  
  

Coverage and Requirements

• Coverage depends on the member’s benefit plan
• Providers must be licensed in the state where the patient is located
• HIPAA compliance is a must—secure connections only
• Modifier 95 is needed to show that visual contact happened
• Documentation must include where the patient and provider were, and what kind of telehealth was used

What is NOT covered

• Non-HIPAA compliant tech (unless CMS says it’s okay)
• Audio-only calls, emails, texts, or faxes—unless it’s an e-visit, virtual check-in, or provider-to-provider consult
• Chiropractic manipulations, dental procedures, and acupuncture

Do you know: The Importance of Anatomical Modifiers in Medical Coding

Anatomical modifiers play a critical role in medical billing and coding by indicating the specific body area or site where a procedure was performed. Their use provides necessary detail to accurately represent the services rendered, supporting clean claims, and receiving the appropriate reimbursement. For medical coders and billers, understanding and applying anatomical modifiers correctly is essential for compliance and efficiency in healthcare reimbursement.

In the complex world of medical billing, clarity is paramount. Anatomical modifiers help prevent the risk of duplicate services being billed by specifying exactly where on the body a procedure occurred.

Example: Use of Anatomical Modifier with CPT 11751

Consider CPT code 11751, (excision of nail and nail matrix, partial or complete, for permanent removal). If a provider performs one procedure on the left big toe and a second on the right big toe, anatomical modifiers should be appended to each line to indicate which toes were treated. 

Claims lacking required modifiers or incorrect application are likely to be denied, delayed, or could result in costly appeals.

Common Anatomical Modifiers by Body Region

Conclusion

Anatomical modifiers are essential tools for medical coders and billers. They provide the specificity needed to distinguish procedures performed on different body sites, reduce the risk of duplicate billing, and ensure accurate payment for services rendered. Proper application, alignment with diagnosis codes, and thorough documentation are key to maximizing reimbursement and maintaining compliance. By mastering anatomical modifiers, medical coding professionals help safeguard the integrity of the healthcare revenue cycle.

Provider Directory Validation

Is your provider's directory information up to date?

Our members (your patients) rely on the information listed in the provider directory to select in-network providers for health care services. Validating your information every 90 days ensures our provider directory displays accurate information.

Blue Cross Blue Shield of North Dakota (BCBSND) asks our provider community to validate their directory information through the Availity Essentials Provider Portal and continue to submit changes through the Availity Essentials directory maintenance form. Making these timely changes and validating information every 90 days allows the directory to be the most accurate. This also assists BCBSND in meeting the No Suprise Act (NSA) Federal Mandate and Utilization Review Accreditation Commission (URAC) requirements.

Your provider's information may be suppressed from the directory if validations are not attested at least once per year. Removal from the directory does not change participation status.

Questions?

For assistance follow the Provider Directory Validation process.

Need help with Availity Essentials or login?

• Call Availity Client Services at 800-282-4548
  

For questions about the Provider Directory Validation process, email Provider Credentialing at prov.net@bcbsnd.com.