Blue Cross Blue Shield of North Dakota (BCBSND) is aligning our NextBlue of North Dakota Medicare Advantage plan with our Commercial and Medicaid Expansion lines of business related to unlisted procedure codes and modifier 22. This also follows the Center for Medicare and Medicaid Service (CMS) guidelines and existing provider manual instructions.
These enhancements, related to unlisted procedure codes and modifier 22 are aimed at improving claims processing timeliness, quality, and consistency. Effective Sunday, Oct. 1, 2023, this will be an implemented change for NextBlue requests that are applicable payment policies for the modifiers and unlisted procedure codes. Supporting documentation will need to be submitted with all claims using modifier 22 or unlisted codes.
When mailing or faxing documentation, note the claim number on the coversheet and indicate that the attached documentation is due to modifier 22 or an unlisted code requirement.
NextBlue of North Dakota
PO Box 261124
Plano, TX 75026
Not Elsewhere Classified (NEC) or Not Otherwise Classified (NOC) Codes:
Effective Sunday, Oct. 1, 2023, claims will be denied if no supporting documentation is submitted with the claims billed with unlisted/NOC codes. The denial message will clearly state the specific supporting documentation needed based on the NOC codes. NextBlue will no longer send a medical record request letter. This is consistent with the Medicare Claims Processing Manual.
References: Medicare Claims Processing Manual. Chapter 26-Completeing and Processing Form CMS-1500 Data Set https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26pdf.pdf
Modifier -22 (Increased procedural services):
We have identified existing payment policies for Commercial and/or Medicaid on the Plans’ Provider Portals. Applying similar policies for Medicare Advantage Plans will provide better consistency, quality, and transparency for providers. The table below compares the current procedure to the proposed solution for modifier 22.
Increased procedural services.
100% - All claims pend for medical record review.
The existing plan policy - 120% - if provided documentation supports an increased level of service.
CO252 and C016 Reject code will be used with combination of the following potential remarks:
- An attachment and/or other documentation is required to adjudicate this claim/service.
- Claim/service lacks information or has submission billing error(s).
Contact our NextBlue Provider Call Center at 1-844-753-8039.