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.
Message from Tracy Mohn and Tracy Giere, Managers of Utilization Management.
Tracy Mohn and Tracy Giere oversee our Utilization Management (UM) department here at Blue Cross Blue Shield of North Dakota (BCBSND).
BCBSND operates a multi-dimensional UM Program to oversee and monitor inpatient and outpatient health care services on the precertification list provided to its members. The UM program involves prospective, concurrent and retrospective evaluation of the services provided to members. The program involves the cooperative participation of BCBSND staff, clinicians, contracted hospitals, ancillary providers and members to ensure the program is effective.
UM is designed to review services before, during or after the members care in accordance with the member’s benefit plan. Medical records and pertinent information regarding the member’s care will be reviewed (with input by peer clinical reviewers when necessary) to determine the level of coverage for a service utilizing the members’ benefits and evidence-based clinical criteria.
The UM team will be going live with the new precertification tool called Predictal this Fall. Predictal will integrate with Availity Essentials, enabling you to optimize the efficiency of your precertification submissions and reduce administrative burdens. To ensure you leverage the tool to its full capabilities when we go live this fall, we encourage you to connect with your system’s facility administrator to ensure you have access to Availity Essentials, especially if you do not have access today. More information on Availity Essentials’ functionality, registration, training tips and resources can be found on our website under Availity Essentials.
To increase efficiency for providers, BCBSND will be implementing PA Checkpoint. This tool is an enhancement on the Availity Portal which will provide real-time responses to providers to assist in determining if a given code requires precertification, is experimental or investigative, or does not require review. It also will link providers directly to the medical policies specific to the code entered, increasing efficiency for providers. All responses are tracked through Availity, and providers will receive a tracking number. The goal of this tool is to improve provider experience and provide timely responses to patient care requests.
If you have questions about UM, please contact 1-800-952-8462.
~ Tracy Mohn and Tracy Giere
Blue Cross Blue Shield of North Dakota’s (BCBSND) Provider Relations Partners and Provider Education teams are planning two virtual Fall 2023 Provider Collaboration sessions.
Proposed dates and times:
Mark your calendars now for an opportunity to join us during one of our virtual sessions and learn updates on our three lines of business: BCBSND Commercial, Medicaid Expansion and NextBlue Medicare Advantage plans.
Registration and the agenda will be shared in late September and/or early October 2023. Continue to watch our HealthCare News (HCN) for further updates. If you are not signed up for HCN, please subscribe through the attached link HealthCare News.
Blue Cross Blue Shield of North Dakota (BCBSND) wants to keep providers informed about the upcoming change to the new precertification tool, Predictal.
As described in our previous HealthCare News (HCN) articles, Predictal is integrated with the Availity Essentials provider portal and designed to provide you a faster pathway for submitting and viewing precertification request(s). The implementation of this tool will go live Fall 2023.
You still have time to verify your Availity Essentials access with your administrator if you will be submitting precertification requests for your office. If you have access to the Patient Registration, Authorization & Referrals tab within Availity Essentials today, you should not need to do anything further.
BCBSND is creating a new online resource to help you navigate this change. When completed, we will provide a notification and place the document under the Resources section of www.bcbsnd.com.
Keep watching our HCN Weekly for additional updates on the new Predictal tool coming soon.
Questions?
If you have any questions regarding this change, contact prov.partners@bcbsnd.com.
For questions related to Availity Essentials registration or administrator functions, contact Availity Essentials Client Services at 1-800-282-4548.
To a Better Future
Blue Cross Blue Shield of North Dakota’s (BCBSND) Caring Foundation is thrilled to be joining Blue Cross Blue Shield Association (BCBSA) in a partnership with Boys & Girls Clubs of America (BGCA) to combat the youth mental health crisis in the U.S. through trauma-informed approaches to behavioral health care.
The BCBSND Caring Foundation is investing in the initiative to help the twenty-three North Dakota Clubs implement trauma-informed practices and training to better support the emotional and mental well-being of kids. Learn more on this exciting new partnership here.
Our members and your patients rely on the accuracy of your information listed in the provider directory to select in-network providers for health care services. Validating your information at least every 90-days ensures the provider directory reflects accurate information.
Blue Cross Blue Shield of North Dakota (BCBSND) is reminding our provider community to continue to submit your changes real-time through the Availity Essentials directory maintenance form. Making these timely changes and validating in a cadence of every 90-days allows for the directory to be the most accurate. This 90-day validation assists BCBSND in meeting the No Suprise Act (NSA) Federal Mandate and the Utilization Review Accreditation Commission (URAC) requirements.
If providers do not attest validation at least annually, your provider information may be suppressed from the directory. However, removal from the directory does not change your participation status.
Questions?
For assistance, follow the Provider Directory Validation process.
Need help with Availity Essentials or login?
For questions about the Provider Directory Validation process, contact Provider Credentialing at:
October is National Breast Cancer Screening Awareness Month. According to the America Cancer Society one in eight women in the United States will be diagnosed with invasive breast cancer in her lifetime, making it the second most common cancer in women. Early detection is key to a better outcome for your patients, and you play an integral role by recommending regular screenings.
Blue Cross Blue Shield of North Dakota (BCBSND) reminds providers of the importance of scheduling regular mammograms for eligible patients. The Breast Cancer Screening (BCS) Healthcare Effectiveness Data and Information Set ® (HEDIS) star measure assesses female patients ages 50 to 74 who had a mammogram to screen for breast cancer in the past two years.
BCBSND supports our members' preventive measures and encourages our members, your patients, of the importance of screenings throughout the year, not just in October. Together we can be effective with early detection.
Questions?
For more information on member benefits, contact the phone number listed on the back of the members' insurance card.
Whether you are familiar with Blue Cross Blue Shield of North Dakota (BCBSND) medical, reimbursement, coding and/or reimbursement policies or not, you may have questioned what all of the dates mean or how to review a prior policy draft.
Below is information to help you understand the basic information at the top of our policies.
First you will see three tabs: Current, Draft and Archive. BCBSND policies will default to the Current tab. If you wish to see the previous version, you can choose the Archive tab. If the Archive tab is grayed out, it means there are no archived drafts available for review. If you have a question about past policies, you will need to contact the Provider Services department on the back of the member's ID card.
Under those three tabs, you will notice additional details, such as, but not limited to:
An additional field will show in the Archive tab, and that is the date the version of that policy was archived.
If a policy did have changes made, you can review those changes at the bottom of the policy.
Please note, the formatting may be different depending on the policy. Here are two examples of the difference.
If a policy has been retired/archived, the Current tab will have a note stating “This policy has been Archived effective September 04, 2023. Click the Archive tab above for more information.”
Example:
Questions?
Additional information regarding policies can be found in the applicable provider manual.
