How does the system upgrade impact Participating Providers?

The items below outline the changes you should be aware of as a BCBSND participating provider:

Migration of Membership
To transition to the HMHS platform, we'll migrate current members from our existing claims processing system to the new platform. Our members will begin transitioning to the new platform July 1, 2018, with the majority of our membership transitioning on January 1, 2019. Blocks of membership will migrate on a monthly basis for a period of six months.

Because of the migration schedule, you will see members with claims processing on our current platform and members with claims processing on the new platform for a period of six months.

Member ID Cards
Members will receive new ID cards that will include a new prefix as part of their subscriber number. The new prefixes are as follows:

New Member ID prefix table

YEP – Individual, on exchange (January 1, 2019 migration)
YER – Individual, off exchange (January 1, 2019 migration)
YQW – Medicare supplement (January 1, 2019 migration)

New Online Portal
In collaboration with our transition to HMHS, BCBSND has also partnered with Availity to make it easier for you to manage the health care of your patients online. BCBSND now offers the Availity Provider Portal, a multi-payer site where you can use a single user ID and password to work with us and other participating payers online. There is no cost for providers to register or use any of the online tools. The Availity Provider Portal will replace our existing THOR Provider Portal and will be your new online method to do things such as:

  • Submit eligibility and benefits inquiries
  • Submit claims and review statuses
  • View your electronic remittance advice (835)

Medical Policy Summary of Changes
BCBSND will be making changes to some of our medical policies and criteria.  This document contains high level changes to medical policies that will occur as we migrate membership to our new systems.

PDF IconMedical Policy Summary of Changes

New Electronic Data Interchange (EDI)
BCBSND has also partnered with Availity to offer a full suite of EDI health information exchange services through a single online connection to the Availity Intelligent Gateway. Availity Intelligent Gateway facilitates billions of health care transactions and has capabilities to automatically identify anomalies between provider submissions and payer records, creating greater transparency and efficiencies for providers and payers alike. BCBSND now offers the Availity Intelligent Gateway, which will serve as your new method to:

  • Submit claim transactions (837I/P), member eligibility (270), claim status (276), etc., 24 hours a day, seven days a week
  • Receive claim acknowledgement (277CA) and claim payment/remittance advice (835) transactions

Claims Submission
When you submit claims through Availity, we will route each claim to the appropriate system based on the date of service. Claims will not be accepted through NHS EDISS for BCBSND business. As a reminder, you should always include the prefix in addition to the ID number on your claims.

Provider Forums
To help providers better understand our systems upgrade and its impacts, we offered several forums across the state in late May and early June. The frequently asked questions that came up during those sessions can be found PDF Iconhere. We will share information about upcoming forums as the details are finalized.