Happening Now

The Department of Corrections (DOC) group/members will terminate effective Sept. 30, 2025.

No claims will be processed after that date, regardless of the date of service. Claims submitted on or after Oct. 1, 2025, for services before Sept. 30 will be rejected or denied. Providers should contact DOC directly for guidance.

Blue Cross and Blue Shield of Nebraska is updating the frequency of our provider communications to better support your time and attention — while continuing to deliver the same high-quality updates you rely on.

What’s Changing?
Beginning October 2025, we will:

• Transition the Provider Bulletin to a bi-monthly publication schedule
• Shift the Provider Update Newsletter to a quarterly format

These changes are designed to reduce the number of separate communications you receive, while maintaining a consistent flow of timely, relevant information.

What Remains Consistent?
You’ll continue to receive:

• Actionable updates on policies, procedures, and operational changes
• Notifications that support your day-to-day interactions with our plans
• Timely alerts posted to our online bulletin boards: Happening Now and NaviNet^® Plan Central

We’re committed to making provider communications more efficient and impactful — so you can stay informed with confidence.

When dental services fall under medical-surgical benefits, submit claims using the CMS 1500 form. Handwritten claims are acceptable if legible. Be sure to include:

• A “D” in the first position of dental codes
• Tooth numbers and supply descriptions

Incomplete claims will be returned. Need a blank CMS 1500? Download it here.

Network dental providers must use the CMS 1500 form when billing for services covered under a member’s medical benefit plan. As part of your agreement with BCBSNE, you’ve committed to submitting claims for all covered services and accepting our payment as payment in full.

BCBSNE covers oral appliances for obstructive sleep apnea (OSA) under medical benefits. Preauthorization may be required. Please verify with the member’s plan if preauthorization is required - claims without preauthorization may be denied to provider liability.

Dentists should:

• Use CDT codes from the NEtwork BLUE dental fee schedule
• Submit claims using CMS 1500
• Reference medical policy VIII.8 at MedicalPolicy.NebraskaBlue.com

Initial banding should be billed as up to one-third of the total charge. Subsequent billing may be monthly or quarterly:

• Monthly: First of the month, regardless of visit date
• Quarterly: Three-month increments listed on the line charge or in comments

This policy applies to Invisalign as well.

To ensure timely and accurate processing of dental paper claims:

• Use ADA forms from 2012 or newer
• Include the member ID in Form Locator 15 on 2016 and newer forms
• Mail claims to:
  Blue Cross and Blue Shield of Nebraska
  P.O. Box 3248
  Omaha, NE 68180-0001
• Claims submitted on outdated forms will be returned

Helpful resources:

• The Filing Dental Charges on a CMS 1500 document outlines the minimal information required when submitting medical services provided by a dentist using the CMS 1500 form.
• The CMS 1500 form is available on our Find a Form page — your go-to spot for accessing provider forms quickly and easily.

Dental providers may need to verify benefits under the member’s medical policy. If dental benefits are available under the medical policy, claims should be submitted accordingly.

When credentialed with BCBSNE Network Blue PPO Dental, providers are automatically added to GRID and GRID Plus. These networks use the same fee schedule and claims process as Network Blue PPO Dental.

As a reminder, the Consolidated Appropriations Act (CAA) requires certain provider directory information to be verified every 90 days. BCBSNE participating providers must verify and attest to the accuracy of their information in the CAQH Provider Data Portal.

Even if your information has not changed, you are still required to attest every 90 days.

Failure to complete this attestation may result in removal from BCBSNE’s provider directory. Under the CAA, BCBSNE is required to remove providers whose data cannot be verified.

To avoid disruption in your directory listing and ensure patients can find your practice, please log in to CAQH and complete your attestation.

For questions or support, visit the CAQH Provider Data Portal or contact your Provider Partnerships Advocate.

Effective January 1, 2026, Arkansas Blue Cross Blue Shield will introduce a new brand for their National Account members, including those affiliated with Walmart and other Arkansas-based national employers.

These members will now carry insurance cards branded as Skai Blue. A press release announcing this change was issued on October 24, 2025.

What Providers Need to Know:

• Skai Blue is an approved brand under Arkansas Blue Cross Blue Shield.
• These members may present cards that look different from traditional Blue Cross Blue Shield of Nebraska cards.
• Please treat Skai Blue cards as you would any other out-of-state Blue Cross Blue Shield card.
• Always validate eligibility and benefits by calling the number on the back of the member’s card.

An example of the new card is below:

We previously communicated changes to the management of certain specialty drugs under the medical benefit for Medicare Advantage (MA) members. This program expanded to include Commercial members, excluding Educators Health Alliance (EHA) members, beginning Sept. 30, 2025.

The program will further expand to include Educators Health Alliance (EHA) members effective Jan. 1, 2026. Providers should submit specialty drug prior authorization requests for EHA members through the BCBSNE provider portal. To identify EHA members, look for ID numbers that begin with the prefix EHN.

Federal Employee Program (FEP) members are not included in this program—please refer to the contact number on the back of the FEP member ID card for assistance.

During the Dec. 19,2024, provider webinar hosted by Prime Therapeutics Management (Prime), you were informed that prior authorization requests for impacted drugs must be submitted exclusively via GatewayPA.com.

We are pleased to announce the launch of a new NaviNet link titled “Medical Pharmacy Prior Auths (Prime)”, available starting Oct. 16, 2025. This link will allow you to submit and view Prime Medical Pharmacy prior authorizations for all impacted lines of business directly through NaviNet.

Key Implementation Dates:

• Medicare Advantage members – Prior authorization required starting Jan. 1, 2025
• Commercial members (excluding EHA) – Prior authorization required starting Sept. 30, 2025
• NaviNet access for Prime Medical Pharmacy prior authorizations – Begins Oct. 16, 2025
• Educators Health Alliance (EHA) members – Prior authorization required starting Jan. 1, 2026
  
  • Submit requests via the BCBSNE provider portal
  • EHA member ID numbers begin with prefix EHN

Prior Authorization Applies to:

• Physician Office (POS 11)
• Patient Homes (POS 12)
• Outpatient Facilities (POS 19, 22)

Submission & Support:

• Routine requests and clinical guidelines: GatewayPA.com
• Urgent/expedited requests: Call 800-424-1709

We appreciate your support in ensuring that our members continue receiving high-quality and clinically appropriate care. If you have questions, please contact your Provider Partnerships Advocate. 

Blue Cross and Blue Shield of Nebraska (BCBSNE) is updating our Peer-to-Peer procedure (GP-P-003) effective Jan. 1, 2026, to reflect recent system enhancements and align with Nebraska Legislative Bill 77 (LB77).

We are reversing our previous decision to postpone the shortened peer-to-peer request window. Our systems can now support electronic delivery of denial reasons through our portal, enabling providers to take timely action.

Key Updates:

• Request Window: Providers will have 3 calendar days (72 hours) from the post denial determination to request a peer-to-peer review for denials deemed not medically necessary on prospective and concurrent reviews.
• Denial Access: Denial reasons will now be available in portal, eliminating delays caused by mailed notifications.
• Physician Availability: Providers must offer a 2-hour window for the peer-to-peer discussion.
• Missed Request Window: If a peer-to-peer is not requested within the 3-day window, the provider must use the appeal process.

We appreciate your partnership as we continue to improve transparency and efficiency in the prior authorization process.

As of Oct. 1, 2025, BCBSNE has transitioned to electronic remittance advices and payments.

Key Reminders:

• Paper remittance advices are no longer issued. Providers must access 835s through a clearinghouse or view remittance advices in NaviNet.
• Paper checks are no longer an option. Providers must be enrolled in electronic funds transfer (EFT) to receive payments.
• Forms are available on NaviNet. Under the Resources section in Plan Central, please visit the Administrative Updates/Secure Forms section to complete EFT and electronic remittance advice enrollment.
• Dentist exception: Dentists unable to enroll with a clearinghouse may continue receiving paper remittance advices due to limited self-service options in NaviNet.

If you have not yet completed the transition, we urge you to take immediate action to avoid any disruption.

Providers are reminded to follow the appeal submission timelines outlined in the Member Benefit Appeals – GP-X-072 policy. According to the policy, first-level appeals should be submitted within six months of the date of the initial denial.

Appeal submission methods and status checks

• PAR providers must submit appeals via NaviNet. You can check the status directly on NaviNet.
• Out-of-state and out-of-network providers only may submit an appeal using the appeal request form. See Find-a-Form. To check the status, call the phone number located on the back of the member’s BCBSNE ID card.

Additional tips for submitting appeals

• Attach all relevant documentation to support your appeal reason (e.g., corrected billing information).
• Incomplete submissions may delay or prevent review.

For questions or further guidance, please refer to the full policy.

At BCBSNE, we are committed to helping our members with complex medical conditions receive the care they need in the most cost-effective manner.

Starting Jan. 1, 2026, we will be removing Humira and Stelara from the following prescription drug lists: NetResults Performance, TraditionalRxList, ValueRxList and BluePride RxChoices. There are multiple biosimilar options available which are, in many cases, interchangeable with Humira or Stelara and will work the same.

Affected medications:

• Humira (adalimumab) and Stelara (ustekinumab)

Preferred biosimilar products:

• Humira:
  
  • Adalimumab-aaty
  • Adalimumab-adaz
  • Hadlima
  • Simlandi
• Stelara:
  
  • Selarsdi
  • Steqeyma
  • Yesintek

Implementation details:

• Starting Jan. 1, 2026: Patients currently on Humira or Stelara will need to switch to a preferred biosimilar alternative for treatment.
• New therapy patients: Patients new to therapy will need to use a preferred biosimilar agent, per policy.
• Preauthorizations: Current preauthorizations extending beyond Jan. 1, 2026, will be transitioned to the biosimilar equivalent medication. Upon expiration, a new preauthorization request for the biosimilar medication will be required as is required today.

For questions regarding coverage, please refer BCBSNE members to call Member Services at the number on the back of their ID card.

Note: These changes do not apply to MA members or members using other BCBSNE prescription drug lists.)

The Electronic Remittance Advice (ERA) form is now available as an online form on the Find a Form page.

Providers should begin using the online form immediately for all ERA submissions. The PDF version should no longer be used or emailed.

Starting Oct. 15, 2025, any ERA form submitted via PDF will be returned with instructions to resubmit using the online form. These submissions will not be processed.

Submitting through the online form improves processing speed, reduces errors, and enhances security. It also supports efforts to reduce paper use and streamline workflows.

Thank you for your attention to this change and for helping make the transition a success.

Effective July 31, 2025, Blue Cross and Blue Shield of Nebraska (BCBSNE) has discontinued its practice of requiring medical necessity reviews beginning with the 91st outpatient visit for mental health and substance use disorder (MH/SUD) services in a single calendar year.

This change streamlines the review process and reduces the administrative burden for providers.

Providers are encouraged to review their processes and update any internal documentation accordingly.

Starting Nov. 18, BCBSNE is making it easier for providers to manage drug prior authorizations (PAs) with the launch of CoverMyMeds.

What’s changing?

• Real-time eligibility checks to confirm coverage before submitting
• Electronic PA submissions - no more faxing paper forms
• Immediate confirmation of receipt - no need to call or resubmit
• Faster processing and reduced administrative burden

These updates are in line with our commitment to reimagining preauthorizations and improve provider experience.

We want to let you know about an upcoming change to our weekly batch claim payment schedule that will go into effect Nov. 1, 2025. We wanted to give you advance notice so you can analyze and prepare for the short-term impact this change will likely have on your organization.

Starting Nov. 1, each weekly batch claims payment will be comprised only of claims with receipt dates of at least 21 days. We are also shifting the weekly payment settlement date from Thursdays to Mondays. This change applies to all Blue Cross and Blue Shield of Nebraska (BCBSNE) lines of business, excluding the Federal Employee Program (FEP).  

We are making this change to reduce the need for post-payment corrections, which causes an administrative burden for providers and confusion for patients. In addition, we are subject to audits and validations to demonstrate accuracy for much of our government business, including Medicare Advantage and ACA plans.  Making this change ensures we have sufficient time to review and validate claims prior to payment.

This new payment cadence supports our ability to continue to provide you with timely payment in alignment with industry standards. Other carriers’ payment cycles range from 21-45 days.

Illustration of difference between current and new payment schedules

Short-term impact of payment cycle change

Because only claims with receipt dates of 21 days or more will be included in each weekly batch, it should be anticipated that for the first three weeks of the new schedule, your organization’s reimbursement amount will be lower than previous weeks, until the new cycle aligns with the adjusted cadence.

Improving the efficiency of our payments to you, as well as making interactions with the health care system less complicated and confusing for our members, are among our top priorities. If you have any questions about this upcoming change, please email Provider Partnership Director Dana Medeiros at Dana.Medeiros@NebraskaBlue.com with the subject line, Payment Schedule Change.

What is value-based care?

Value-based care (VBC) is a care delivery model that emphasizes quality and efficiency, with the goal of better health outcomes and experiences for members and providers. BCBSNE partners locally with primary care physicians to help coordinate care, keep quality high and lower the growth of health care costs.

What are the key principles of value-based care?

• Patient-centered: Care is designed around an individual’s needs, goals and preferences.
• Quality over quantity: Providers are rewarded for improving patient health outcomes, not for the number of tests or procedures performed.
• Coordinated care: Emphasizes collaboration among providers to ensure seamless, holistic care.
• Cost efficiency: Encourages the reduction of unnecessary services and promotes preventive care to lower overall health care costs.
• Accountability: Providers are held responsible for both the cost and quality of care delivered to their attributed patient population.*

*Dependent upon the type of agreement between BCBSNE and the contracting entity.

What value-based care agreements are available at BCBSNE?

BCBSNE offers VBC agreements to:

• Accountable care organizations (ACO):
  • Three-year term
  • Shared saving/risk models
• Patient-centered medical homes (PCMH):
  • One-year term
  • Pay-for-quality model
• Independent clinics:
  • One-year term
  • MA population
  • Pay-for-quality model

Eligibility criteria exist in each agreement offering and must be met to be eligible for participation.

Are all providers eligible to participate in BCBSNE’s value-based care agreements?

Currently, the following provider specialties are eligible to receive attribution in BCBSNE’s base value-based care agreements:

• Advanced Registered Nurse Practitioner*
• Family Practice
• General Practice
• Geriatric Medicine**
• Gynecology
• Internal Medicine
• Nurse Practitioner*
• Obstetrics-Gynecology
• Pediatrics
• Physician Assistant*
• Preventive Medicine

*These providers can only be considered as eligible primary care physicians if practicing under one of the other provider specialties listed.

**Specific to Medicare Advantage Attribution

For further inquiries regarding our VBC opportunities, please contact VBPQuestions@NebraskaBlue.com.