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.
September is Suicide Prevention Month, and as September ends, we recognize the impact suicide may have on our provider communities, families, employees and workplace. We also recognize that suicide is a complex public health challenge impacting people of all ages, genders and ethnicities. Blue Cross Blue Shield of North Dakota (BCBSND) assists in prevention efforts through our provider community resources, our BCBSND.com website resources and member and employee education.
Suicide can be preventable. Recognizing the potential signs of suicide is one way to aid prevention. Studies show that about 80% of those considering suicide give some sign of their intentions.
While there is no single cause or risk factor, we can assist in saving lives by knowing some steps for suicide prevention, we strongly encourage our provider community, BCBSND members and BCBSND employees to understand the signs of suicidal tendency.
These may include:
Help is always available at 988!
Don’t ignore suicidal thoughts or actions. If you are worried about a loved one, friend, yourself — anyone — trained counselors are ready now and always available. The National Suicide and Crisis Lifeline is free, confidential and open 24/7.
Call or text 988, or chat at https://988lifeline.org/
It has been a busy 2024, as we enter Quarter 4 and approach the end of 2024, BCBSND wants to keep our provider community aware of the changes we have made so far. We also want to inform providers of things to expect in 2025.
We continue movement with the following changes:
We will continue to keep our provider community informed of movement into these changes through website updates and our HealthCare News.
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BCBSND has changes coming for clinician administered drug prior authorization (also known as precertifications or prior approvals) requests for our Commercial and Health Insurance Marketplace members. The change coming will affect how providers request prior authorizations for clinician administered drugs on the medical benefit.
BCBSND will be working with the Medical Pharmacy Solutions team at Prime Therapeutics Management (Prime) to assist with clinician administered drug prior authorization reviews. We want to assure providers that BCBSND will be ready later this year to answer questions and serve your needs.
We will have resources and virtual training sessions available prior to our transition. Watch the HealthCare News section of our website for upcoming news and learning opportunities.
NOTE: This new process will not change the retail pharmacy prior authorization process through the pharmacy benefit.
Beginning Jan. 1, 2025, the CMS 45 CFR 156.230(a)(2)(i)(B), will require Qualified Health Plan (QHP) issuers including stand-alone dental plans (SADPs) issuers, in the Federally Facilitated Exchanges (FFEs) to meet appointment wait time standards established by the FFEs. We wanted to make you aware of an upcoming requirement from CMS that was shared with payers in the 2025 Final Letter to Issuers in the Federally-facilitated Exchanges (cms.gov)
New patients will be a focus to ensure they can be seen by in-network providers.
This grid gives providers an idea of what BCBSND will be seeking as access from our in-network providers:
Provider specialty type | Appointment must be available within |
|---|---|
Behavioral Health | 10 business days |
Primary Care (Routine) | 15 business days |
Specialty Care (Non-urgent) | 30 business days |
As an extra part of these requirements, BCBSND is looking to hire a third party to survey our in-network providers for these access and availability standards. We do have a survey process today that you may be aware of, however, this survey will be larger in scale and will also need to be done by a third party.
After we receive the results, BCBSND will work with provider organizations that are not meeting these standards to understand potential barriers.
We will also be supplementing this requirement with a more general wait time survey that will come out sometime in Quarter 1 of 2025.
BCBSND would like to remind our provider community of the participating provider agreement section Provider Group’s Responsibilities 3.11 of your BCBSND provider agreement.
The Provider Group and its Providers shall submit claims and supporting documentation as requested for covered services on behalf of a member unless exempted under state or federal laws and regulations (i.e., Health Information Technology for Economic and Clinical Health Act (HITECH Act)). Services shall be submitted on the appropriate claim forms, according to industry standards or as determined by BCBSND policy.
To remain compliant to your signed contract, providers may provide a discounted rate as indicated below, however services should not be given at a discounted rate for not submitting the claim to the member’s insurance plan.
BCBSND defines a member discount as any promotion or special consideration that reduces the provider’s customary charge for covered services. Participating providers offering member discounts must adhere to the following guidelines:
Description | Amount |
Provider's Customary Charge | $100 |
BCBSND Allowance | $85 |
Questions?
Contact the appropriate Provider Service Center number listed on the back of the members ID card. For questions related to a provider contract contact the BCBSND contracting team at provider.contracting@bcbsnd.com.
We understand that the Payment Integrity Program can be confusing. We want to help give a high-level overview of the program, the why behind it and resources to help providers navigate more efficiently.
What is it and why is this program necessary?
The Payment Integrity Program is integrated into the BCBSND claims processing system to enhance current capabilities to ensure payments are correct, assigned to the right payer and consistent with national standards and guidelines.
To whom does this program apply?
All providers who submit claims for BCBSND Commercial, FEP and Medicaid Expansion members.
Where can I find more information?
There are multiple places information can be found. This includes:
From the main webpage, you can:
As an example, you can see by clicking on Clinical Chart Validation (CCV), it has multiple pieces to the process.
By expanding the plus sign, you can drill down to additional detail. Section(s) will include copies of sample letters a provider can expect to see, when applicable. You will also notice the Reconsideration timelines noted on the side of the page if one applies.
Additional reminders:
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.
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 for 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 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?
For questions about the Provider Directory Validation process, contact Provider Credentialing at:
