June 2023 Quarterly Provider Insights

June 2023 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 Appeals

Message from Celine Schmidt, Manager of Medical Policy, Appeals and Grievances

My name is Celine Schmidt and I oversee our Medical Policy and Appeals department here at Blue Cross Blue Shield of North Dakota (BCBSND).

Today, we are going to focus on the appeals aspect of BCBSND. As we know, appeals are a part of any insurance company. Having the option for an appeal allows a provider to submit additional information to support more details of necessity a member may have had, that may not be showcased on a claim because of the information allowed on a 1500 or UB04 claim form. For 2023, our Appeals team has received 100-150 appeals on average per day.

While speaking of appeal submissions, we look forward to the use of our new electronic Appeals form that will become available in the near future. The electronic version of this form will enhance user experience and include attaching files, cutting out the mailing process and timeframes associated with mailing. More information on this to come!

We hope to continue to hear positive feedback regarding this new form's implementation and look forward to other ways to better serve our provider community.

~ Celine Schmidt


News and Announcements

Predictal Itiliti Health logo

New Precertification Tools Coming by End of Year

Blue Cross Blue Shield of North Dakota (BCBSND) is excited to announce that we are implementing two new tools, Predictal and Itiliti Health to our precertification functionality within our Provider Portal, Availity Essentials later this year. BCBSND is excited to partner with these two vendors to streamline your provider experience with precertification's.

The Predictal tool will provide a faster pathway to submit a precertification's through the Provider Portal, Availity Essentials, as providers will access the Predictal Portal directly through a single sign on (SSO) to complete the online precertification. The request will be directly routed to a nurse for review thus skipping the manual set up needed for faxed submissions. Our NextBlue of North Dakota Medicare Advantage plan will not be part of this change.

The Itiliti Health tool checkpoint will provide real-time responses to providers who submit precertification's to assist in determining if the service requires precertification. It also will link providers directly to our medical policies, which should increase efficiency for providers. Itiliti Health will allow for faster determinations, with real-time response. All responses are tracked through Availity, and providers will receive a tracking number. This will also improve more timely patient care requests and reduce the administrative burden, which will lead to provider savings. Our NextBlue of North Dakota, Medicare Advantage plan and Federal Employee (FEP) lines of business will not be part of this change.

Our BCBSND Utilization Management (UM) team will be able to self-administer these new tools. It allows us to enhance our provider and member precertification search capabilities on the web and allow Utilization Management to control the coding changes and updates as they come out.

Watch our HealthCare News (HCN) weekly as we will keep you all updated with any educational opportunities for the tools we implement. If you are not registered for HCN weekly, please register here: HealthCare News.

School buses lined up on street

Blue Cross Blue Shield of North Dakota Caring Foundation News

Behavior and Mental Health and Rural Living

May’s Mental Health Awareness Month has ended, but Blue Cross Blue Shield of North Dakota (BCBSND) is in continued support of behavioral and mental health awareness throughout the year and always looking to make a difference in North Dakota.

After receiving one of the Caring Foundation SPARK Grants last fall, Northern Cass Public School started paving the way for increased mental health services within their school. The grant went towards improving behavioral and mental health services by expanding the availability of an on-site certified therapist to reduce wait times and provide more regular sessions for students.

Behavioral and mental health issues do not relate to just small towns and rural living in North Dakota, they impact our entire state. This grant is making a difference and has impacted a small rural community.

We applaud our Provider Community in making a difference in the health and well-being of your patients, our members, in all efforts to recognize and provide support for behavioral and mental health awareness, not just in the month of May but throughout the entire year.

To learn more about our Caring Foundation, please visit BCBSND Caring Foundation.


Educational Topics


No Surprises Act (NSA) Directory Validation 

Midyear 2023 is approaching, Blue Cross Blue Shield of North Dakota (BCBSND) is reminding our provider community that providers are required to validate your provider directory information once a year. As a requirement of the NSA, we are following the federal mandate.

There is still time to validate to make sure your 2023 information is up to date. Validating your information ensures our directory reflects accurate information. Our members and your patients rely on the provider directory to assist in finding health care services available within their network.

As new patients and providers join our network, the directory informs providers and our members that you are available. When your information is not correct, this may cause members and provider referrals to go elsewhere.

Follow these instructions to complete the directory validation process.

Need help with Availity Essentials or login? 

  • Call their Client Services at 1-800-282-4548.

For questions about the Directory Validation process, contact Provider Credentialing at:

Employees working in a call center

Working to Make a Difference in our Commercial Provider Service Center

Blue Cross Blue Shield of North Dakota (BCBSND) thanks providers for your continued patience as our Commercial Provider Service Contact Center has high call volumes and wait times in the first two quarters of this year.

From our original HealthCare News (HCN) publication on February 16, 2023, Provider Service Contact Center Call Volumes and Wait Times we have seen improvements in our call volumes and wait times, since providers are using additional resources provided in the original article.

We are seeing an increase of providers accessing self-service tools, as a reminder the self-service tools available:

  • Interactive Voice Response (IVR) 
  • Check claim status
  • Verify eligibility
  • Verify cost shares accumulated
    • Some services are excluded
  • Availity Essentials  
    • Eligibility and benefits verification
    • Direct messaging
    • Viewing your electronic remittance advice (ERA) 

As a reminder to keep providers informed, we place banner messaging on the BCBSND Provider website if or when we are experiencing high call volumes or scheduled, or system down-time as shown below. We also notify providers through the banner messaging for additional unplanned downtime and closures. 

Please refer to the original Provider Service Contact Center Call Volumes and Wait Times

Electronic Funds Transfers (EFT)

To sign up for Electronic Funds Transfers (EFT), providers must have successfully enrolled for Electronic Remittance Advice reviewer (ERA) via our Provider Portal, Availity Essentials. Enrollment for access is assigned by the Providers Availity Essentials Administrator.

Providers who participate in all our plans Commercial, Medicaid Expansion and/or NextBlue of North Dakota Medicare Advantage, can only have one bank account on file at a time. 

To get enrolled with EFT:

  • Log in to Availity Essentials
  • Click on the Claims & Payments dropdown
  • Select Transaction Enrollment
  • Click Enroll
  • Follow through the prompts to submit your request
  • When inputting the National Provider Identifier (NPI) number, ensure you are using the group NPI, not an individual practitioner's NPI

Providers can check EFT submission progress status at any time by accessing the Transaction Enrollment page within Availity Essentials. EFT applications can take up to 60 days to be reviewed and completed.

Once approved, providers will see the approved EFT status, with a note confirming the EFT effective date. Until that effective date begins, providers will receive paper checks in the mail.

  • Any reimbursement for claims submitted prior to the EFT effective date will arrive as paper checks.
  • Reimbursement for claims submitted after the EFT effective date will be sent payment electronically.

For additional questions regarding enrolling for an EFT contact Availity Essentials at 1-800-282-4548.

Corrective Action Policy (CAP) Updated

Blue Cross Blue Shield of North Dakota (BCBSND) has made updates to the Corrective Action Policy (CAP). This policy ensures BCBSND implements timely, effective actions when indicators reveal a need for improved performance by a Health Care Provider.

This policy outlines how BCBSND may initiate corrective action if a Health Care Provider does not comply with BCBSND's performance standards. As a member owned organization, BCBSND has a responsibility to ensure payments are not made for unnecessary, inappropriate, or harmful services.

To learn more visit: Medical Management Corrective Action Plan.