March 2026 Quarterly Provider Insights

REQUIREMENTS: IMMEDIATELY (High Priority - Directory Validation): - Billing and front office staff must ensure provider directory information is validated every 90 days through Availity Essentials Provider Portal using the Directory Maintenance form - Medicaid Expansion providers are subject to random monthly sampling reviews; failure to complete validation attestations will result in directory suppression - Any practice changes (address, phone, specialty, accepting new patients, languages, tax ID, NPI changes, staff additions/departures, mergers) must be reported immediately via Directory Maintenance form - Flag for billing team: Medicaid Expansion providers with no claims submitted within 12 months will be removed from directory and dis-enrolled from Medicaid Expansion Network; 3-month prior notification will be sent - Action: Complete the Update Provider Information form if previously removed; note in free text that claims have been submitted and request reinstatement BY END OF 2026 (Maternity Coding Transition): - Billing team must begin transitioning from global maternity billing to non-global maternity billing practices (system currently allows this) - Monitor for education materials and billing guidance expected mid-to-late 2026 - Prepare for January 1, 2027 effective date when global maternity coding will NO LONGER be accepted - Action: Track impacted CPT codes and billing scenarios from BCBSND; update billing software and provider education materials before 01/01/2027 ONGOING (Member Billing Compliance): - Billing team must verify member eligibility and benefits PRIOR to service rendering - Front desk and billing staff training: collect ONLY the member cost-share listed on Explanation of Benefits (copayment, coinsurance, deductible) - Prohibited charges: do NOT bill for covered services already paid by health plan, do NOT collect amounts above required member cost-share, do NOT bill administrative/operational fees not permitted under contract, do NOT require upfront payment beyond member cost-share - Process: Review provider contract and BCBSND resources; compare EOB to charges before billing member; issue prompt refunds if incorrect charges identified - Consequence: Non-compliant billing may result in member complaints, administrative review, corrective action, and erosion of provider credibility - Contact for billing questions: Provider Service 800-368-2312 (Commercial) or 833-777-5779 (Medicaid Expansion)