Happening Now

Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to making processes easy and efficient for providers. The fastest and most reliable way to submit requests is through NaviNet^®, our secure online portal.

Appeals and reconsiderations for PAR (participating) providers cannot be submitted by mail or fax. Requests sent by mail or fax will not be processed. To avoid delays, submit requests electronically via NaviNet.

For details and access to the form, visit our Provider Academy page, where you’ll find eLearnings and FAQs with guidance on correct submission options.

Thank you for your attention and collaboration as we implement this updated process.

Blue Cross and Blue Shield of Nebraska is standardizing payer ID usage and claim acknowledgement processes to simplify electronic claims submission and improve consistency across Commercial, Dental and Medicare Advantage lines of business. Providers should continue working with their practice management system vendor or clearinghouse to ensure payer ID configurations are updated for the appropriate payer ID: 77780 for Commercial and Dental, A6492 for Medicare Advantage (as of Jan. 1, 2027).

Beginning Jan. 1, 2027, BCBSNE will also retire the Claim Confirmation Report and move to the standard ASC X12 277CA claim acknowledgement transaction for all trading partners. Additional details, including payer ID guidance, timing and readiness steps, are available in the August provider newsletter found in the Alerts & Updates for Providers page.

To help ensure inpatient surgical services are reviewed consistently and supported by appropriate clinical information, BCBSNE has updated the way inpatient surgical authorization requests are processed.

What's changed?

• Requests no longer receive immediate approval through the portal workflow
• Requests are routed to a nurse reviewer for clinical review before an authorization determination is made

What's stayed the same?

• Providers submit inpatient surgical authorization requests through the provider portal
• Authorization requirements remain unchanged
• Medical necessity criteria remain unchanged
• No additional action is required from providers at this time

What should providers expect?

• Requests that previously received immediate approval through the portal will now require clinical review before a determination is made
• Providers may be asked to submit clinical documentation to support the request
• This change is intended to improve review accuracy and help ensure services meet medical necessity requirements
• To help support timely review and determination of your request, include applicable surgical CPT codes in your notes and any submitted clinical documentation

Providers should continue submitting requests through the provider portal. BCBSNE will request additional clinical documentation when needed to support the review process. 

BCBSNE is proud to welcome State of Nebraska employees and their dependents back beginning July 1, 2026, bringing approximately 28,000 members into BCBSNE medical and pharmacy coverage.

This transition supports strong access to care through NEtwork BLUE, Premier Select BlueChoice and BluePrint Health. Providers are encouraged to review each member’s ID card at every visit to confirm network selection and benefits. Participation details are available at NebraskaBlue.com/DoctorFinder.

Pharmacy drug coverage follows the Broad Network C, and NetResults Biosimilar Plus (PDL 25) formularies.

Members will have access to a variety of supportive programs designed to enhance care, including:

• Virta Health for diabetes management
• Progeny Health for maternity and NICU support
• Hinge Health for virtual physical therapy
• Nurse-supported programs that provide personalized guidance across a range of health needs

We appreciate your continued partnership in helping members achieve their best health and experience a smooth transition.

Effective September 1, 2026, Blue Cross and Blue Shield of Nebraska will require providers to submit appeals, reconsiderations, and other claim-related requests using the appropriate submission type and channel.

To help ensure timely review and processing, requests submitted under the incorrect category may be returned with instructions for resubmission. Examples include:

• Appeals submitted as claim reconsiderations
• Claim reconsiderations submitted as appeals
• Medical records submitted through an incorrect submission pathway when alternate instructions have been provided

Providers should carefully review the submission options available through NaviNet^® and follow any instructions included in correspondence from BCBSNE regarding how and where supporting documentation should be submitted.

Submitting requests through the correct pathway helps:

• Reduce processing delays
• Improve routing accuracy
• Ensure timely handling of appeals and reconsiderations
• Minimize administrative rework for both providers and BCBSNE

If a request is returned because it was submitted under the wrong request type, the return notification will include instructions on how to submit the request correctly.

We encourage providers to review their internal processes and educate staff responsible for submitting appeals, reconsiderations, and supporting documentation prior to the effective date.

Thank you for your partnership and commitment to efficient claims and appeals processing.

Effective immediately, ProgenyHealth will manage additional neonatal cases for groups that elect ProgenyHealth services.

What's changing?

ProgenyHealth will manage:

• Infants admitted to the NICU or PICU within the first 28 days of life.
• Subsequent admissions for those infants through their first birthday if they were admitted to the NICU or PICU within the first 28 days of life.

What remains unchanged?

Blue Cross and Blue Shield of Nebraska will continue to manage:

• Infants who were not admitted to the NICU or PICU within the first 28 days of life.
• Infants admitted only to other levels of care, such as a well-baby nursery.

This enhancement supports continuity of care for eligible infants and helps ensure consistent case management throughout the first year of life.

Thank you for your continued partnership and commitment to delivering high-quality care for our members.

As a reminder, BCBSNE continues to partner with Conduent to conduct coding reviews of Emergency Department (ED) claims to support accurate and consistent reimbursement. Providers who wish to submit a second-level appeal related to an ED coding review should send their appeal and supporting documentation to PaymentIntegrityProviderReviews@NebraskaBlue.com.

To help reduce administrative burden, providers may submit multiple ED coding review appeals as a single bulk submission rather than sending appeals individually. We encourage providers to use the bulk appeal process whenever possible.

We're introducing a new Outpatient to Inpatient 3-Day Window policy effective Sept. 15, 2026. This policy applies to facility claims and provides guidance on reimbursement for preadmission and preoperative services. Review the policy for complete details and requirements.

View the full policy. 

New medical policies will be implemented effective July 1, 2026. Please review these updates prior to the effective date.

Policies included:

• Quantitative electroencephalography as a diagnostic aid for attention-deficit/hyperactivity disorder, cognitive impairment or autism spectrum disorder
• Compression pumps for treatment of lymphedema and venous ulcers
  
• Postsurgical home use of limb compression devices for venous thromboembolism prophylaxis
  
• Ophthalmologic imaging techniques for glaucoma and anterior eye segment evaluation
  
• Scintimammography and gamma imaging of the breast and axilla

Action required:

Review full policy details, including clinical criteria and coverage guideline from Medical Policy or on NaviNet Plan Central.

CAQH is now DataSpring, powered by CAQH. The new brand reflects the organization’s central role in delivering a connected healthcare ecosystem through accurate, authorized data from providers and payers. DataSpring enables the industry to operate more efficiently and deliver better experiences and outcomes for providers, payers and patients.

The Centers for Medicare and Medicaid Services conducts an annual Risk Adjustment Data Validation audit. The audit verifies diagnosis codes submitted for payment and the corresponding medical records.

Blue Cross and Blue Shield of Nebraska (BCBSNE) begins the process of retrieving medical records in June.

Under the terms of your contract with us, healthcare professionals and facilities agree to submit requested medical records to BCBSNE in a timely manner and at no cost to the patient or BCBSNE. Patients have already consented to the release of medical records to BCBSNE, and no additional authorization is required for this audit.

All information obtained as part of the review process is confidential.

The March 2026 Provider Bulletin marked the sunset of this publication. 

Blue Cross and Blue Shield of Nebraska (BCBSNE) continues to enhance provider communications by focusing updates through established, effective channels. Over time, provider communications have evolved with an emphasis on clarity, consistency and reduced duplication. Information previously shared in the Provider Bulletin is now delivered through channels providers already use for timely updates and operational guidance. 

Beginning in April 2026, the Provider Bulletins will be retired. BCBSNE will focus communications through the Provider UPDATE newsletter, a monthly publication, along with real-time communications available through our provider portal as well as Happening Now.   

Provider Update newsletter

The Provider UPDATE newsletter remains BCBSNE’s primary periodic publication. Published monthly, it includes policy updates, operational reminders, claims and billing guidance and other important information in a single digital format designed for easy reference. The UPDATE is an amendment to your provider agreement and contractual relationship.  

Providers are encouraged to: 

• Review the monthly Provider UPDATE newsletter for ongoing updates and reminders 
• Log in to NaviNet or check Happening Now regularly for announcements and time-sensitive information 
• Use NebraskaBlue.com as the primary reference for forms, policies and operational guidance 

BCBSNE remains committed to clear, consistent and meaningful communication with the provider community. This transition reflects our continued focus on delivering important information through tools that best support provider needs.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is pleased to announce a new partnership with ProgenyHealth to enhance maternity care and support healthier pregnancies beginning June 1, 2026.

ProgenyHealth is a national leader in maternity and neonatal care management, working collaboratively with health plans, providers and hospitals to support evidence‑based care throughout the perinatal journey. This partnership supports BCBSNE’s mission to make a lasting difference in the lives of members by improving health outcomes and care coordination for mothers and newborns.

Through this maternity program, eligible members gain access to specialized care management focused on healthy pregnancies, early identification of risk and coordinated support before and after delivery. ProgenyHealth’s experienced clinical team works alongside providers to promote best practices, reduce avoidable complications and support positive birth outcomes.

Member Identification and Eligibility in NaviNet

Providers should begin by accessing NaviNet to locate and review the subscriber or member information for active eligibility.

• Log in to NaviNet
• Search for the subscriber or member using available demographic information
• Navigate to the Benefits and Eligibility section

Identifying ProgenyHealth Enrollment

Once eligibility is confirmed, providers must determine whether the member is enrolled in the ProgenyHealth maternity program. Enrollment status is displayed in the Benefits and Eligibility section in NaviNet when a member is in session.

This step is critical, as notification and authorization workflows differ based on ProgenyHealth enrollment.

BCBSNE values its partnership with providers and looks forward to working together with ProgenyHealth to support healthier pregnancies and growing families across Nebraska.

Additional information about the ProgenyHealth maternity program is available at progenyhealth.com/portal/bcbsne-providers. Providers can access program resources, referral form and download a flyer to share with members.

We are excited to share an upcoming enhancement that supports efficient care delivery and reduces administrative steps for providers caring for commercial members.

What providers can expect
Observation stays (OBS) will follow a streamlined process that allows providers to focus on patient care while supporting appropriate utilization management for inpatient services.

Under this update, observation services may be provided for up to 48 hours. When a member’s clinical condition supports an inpatient admission, authorization is requested at the point inpatient status is determined.

Inpatient precertification details
Precertification continues to apply to inpatient (IP) admissions for commercial members.

• Authorization is requested when inpatient status is initiated
• This applies regardless of when the admission decision occurs during the stay

Observation to inpatient transitions
For members who transition from observation to inpatient status:

• Same-day transitions: If inpatient admission occurs on the same date as observation, providers submit an authorization request for the inpatient stay
• All OBS to IP transitions: Authorization is requested when inpatient care begins

Important reminders

• This enhancement applies to commercial plans only
• Observation stays follow the updated process
• Inpatient admissions continue to follow precertification requirements

Additional guidance and details are available in Preauthorization and Precertification (GP-X-014).

We appreciate your continued partnership and look forward to supporting you with improvements that promote timely care and administrative simplicity.

For questions or support, providers have three options to connect with BCBSNE.

1. Check NaviNet^®, where fee schedules and many claim details are available, if you have a claim question, start with a Claims Investigation inquiry in NaviNet to receive a reference number and track resolution
2. If the issue is not resolved, submit a Provider Advanced Inquiry (PAI) using the Claims Investigation reference number to ensure proper routing
3. If online options aren’t viable, providers may also contact the Customer Support Center at 800‑635‑0579 for assistance

BCBSNE is partnering with Cotiviti to conduct short stay and clinical chart validation reviews. These reviews will assess whether inpatient admissions were clinically appropriate or should have been billed as outpatient or observation services.

This program applies physician clinical judgment and nationally recognized clinical guidelines to support accuracy, consistency, and alignment with established clinical and billing standards.

What to expect
Short stay and clinical chart validation reviews focus on inpatient admissions with a length of stay of two days or less. During the review, the complete medical record is evaluated to determine whether the inpatient admission met applicable clinical criteria.

Reviews are conducted using:

• InterQual^® or MCG^® guidelines
• The CMS inpatient‑only list

These reviews may also be referenced using common industry terms, including:

• Short stay audits
• Observation audits
• Place of service audits
• Appropriateness of admission reviews
• Length of stay audits

If a review determines that inpatient criteria were not met, the inpatient claim may be denied and the provider will be advised to rebill the services as an outpatient claim, when appropriate. 

How claims are selected
Claims are selected for review based on a combination of clinical and administrative factors, including but not limited to:

• Length of stay
• Diagnosis‑Related Group (DRG) billed
• Procedures performed, when applicable
• Discharge status

A proven and collaborative approach
This review program is supported by Medicare policy, client medical policies, and nationally recognized clinical and billing guidelines. It is designed to complement existing prior authorization and concurrent review activities, reinforcing appropriate admission decisions while minimizing unnecessary disruption.

Reviews are conducted by Cotiviti’s experienced registered nurses, with physician oversight, leveraging deep expertise in clinical documentation, utilization management, and claims accuracy.

Regulatory support
Short stay reviews are supported by CMS regulations and, in most states, applicable Medicaid regulations. CMS guidance emphasizes that inpatient admission is appropriate only when a patient’s condition or safety would be compromised in a less intensive setting, and that physician orders must be evaluated in the context of the entire medical record.