BCBSNE enhances prior authorization process to reduce burden and improve access
Blue Cross and Blue Shield of Nebraska (BCBSNE) is joining other Blue Plans and national insurers in a shared commitment to simplify and improve the prior authorization process. These changes are designed to reduce administrative burden, improve transparency and support timely access to care.
As part of this effort, we are also partnering with providers to leverage automation for a more efficient experience. Our goal is to ensure that at least 80% of electronic prior authorization requests are processed in near real-time by 2027 – delivering faster decisions and reducing delays in care.
Key improvements include:
Standardized electronic submissions to streamline provider workflows by 2025.
Reduced prior authorization requirements for certain in-network services by 2026. This work is already underway, with several requirements recently removed (see the Reimagine Preauthorization article below for details).
90-day continuity of care for members switching plans, honoring existing prior authorization approvals.
Clearer communication to members and providers, including personalized guidance and appeal options.
Faster response times, with a goal of near real-time decisions for 80% of electronic requests by 2027.
Physician-led reviews for any denied prior authorization requests.
Extended approval timeframes, including extending the through date of an approved authorization to ease administrative overhead for providers and increase the amount of time a member has to complete the service.
These updates demonstrate our ongoing commitment to supporting providers and improving the health care experience for our members. This initiative also builds on our recent collaboration with the Nebraska Hospital Association and the Nebraska Medical Association on LB77, helping to bring needed standardization to prior authorization processes across Nebraska.
More details can be found in the Reimagine Preauthorization article below.
Announcing our new webpage: Reimagine Preauthorization
We are dedicated to continuously refining our processes and strengthening our partnerships with the provider community. In November 2024, we engaged with providers from across Nebraska, ranging from large metropolitan institutions to small rural practices, to gather feedback on our current preauthorization process. While we received commendations for our strengths, we also identified several areas for improvement.
In line with our commitment to reimagining preauthorizations and the feedback we received from providers, we are excited to introduce Reimagine Preauthorization, a resource designed to keep you informed about the latest updates and enhancements.
Check back frequently to ensure you are up to date on our processes.
Preauthorization procedure updates
You can easily find codes that have been updated or removed from preauthorization review requirements. By consolidating this information in one location, we aim to enhance transparency, reduce administrative burden and improve efficiency. Our goal is to support your office with clear, streamlined information, making your work simpler and more effective.
Insights and innovations in provider collaboration
Explore the latest articles highlighting our ongoing efforts to enhance operational efficiency, strengthen provider partnerships across Nebraska and support continuous learning. Stay informed with updates designed to keep you connected and empowered.
We invite you to explore Reimagine Preauthorization and take advantage of the resources available. Your feedback is invaluable as we continue to improve and innovate our processes. Thank you for your ongoing partnership and commitment to excellence.
NaviNet®: Change to submit appeals, timely filing requests and reconsiderations is now live
On June 26, 2025, a change was implemented to streamline the process for submitting appeals, timely filing requests and reconsiderations via NaviNet. Previously, the system required selecting a “type” (Appeal, Recon or Timely Filing). This has now been updated to select a “reason” from the dropdown menu.
New submission process
To submit a request:
Go to your claim status details.
Click on the Appeal button and select the reason for your request.
Add free-form text, attach any supporting documentation (in PDF format) and submit the request.
These changes aim to simplify the submission process and improve efficiency.
Transition to electronic remittance advices and payments
BCBSNE continues to further our paperless transition with a shift toward electronic remittance advices and payments:
Effective Oct. 1, 2025, paper remittance advices will be discontinued. Providers can receive 835s by signing up with a clearinghouse or accessing remittance advices in NaviNet®.
Effective Oct. 1, 2025, the option to receive paper checks will be discontinued. Providers currently receiving paper checks will need to fill out an electronic funds transfer (EFT) form to receive electronic payments.
Forms available on NaviNet: The necessary forms for signing up for EFT and enrolling in the electronic remittance advice service are available under the Administrative Updates/Secure Forms link on NaviNet. Please complete these steps in advance of Oct. 1, 2025.
Exception for dentists: Due to limited self-service options in NaviNet, dentists can continue receiving paper remittance advices if they cannot enroll with a clearinghouse.
Paper remittance advices and paper checks will no longer be an option for newly credentialed providers effective July 1, 2025.
Alert: Review your demographic data in CAQH every 90 days
To ensure your information remains accurate and up to date, BCBSNE in-network providers are required to verify demographic data every 90 days and attest to your information through your CAQH portal.
Under the Consolidated Appropriations Act, BCBSNE is required to remove providers from our directory whose data we are unable to verify. If you do not complete the attestation in CAQH, and we are unable to verify your information, you may be removed from the directory.
For further information on utilizing CAQH please review our Provider Academy.
Reminder: Advanced provider inquiry (API) case closure
When an API is resolved, the case will be closed. You will receive an email notification indicating its closure. If you have any further follow-up questions, please submit a new API request.
To ensure timely and accurate processing of Medicare Advantage (MA) dental claims submitted on behalf of members, please use the official 2025 Dental Reimbursement Form, available under the Provider MA Forms page on NebraskaBlue.com.
Kindly discontinue the use of outdated American Dental Association claim forms. Utilizing the correct and current form helps streamline the reimbursement process and significantly improves turnaround times.
Improving MA Annual Wellness Visits (AWVs) and Comprehensive Physical Exams (CPEs) completion rates
Current challenge
Current completion rates for MA AWVs and CPEs are currently below desired expectations. This shortfall impacts not only patient health outcomes but also our clinic's performance metrics and revenue streams.
Understanding AWVs and CPEs
AWV: A preventive service covered by BCBSNE focused on creating or updating a personalized prevention plan based on the patient's current health and risk factors.
CPE: This service, also covered by BCBSNE, is a thorough evaluation of a patient's physical health, often encompassing assessments not included in the AWV.
Benefits for patients
Preventive focus: AWVs help in early detection of potential health issues, allowing for timely interventions.
Cost-free access: Medicare covers AWVs at no cost to patients, eliminating financial barriers.
Personalized care plans: Patients receive tailored health advice and preventive care recommendations based on their health status and risk factors.
Benefits for providers
Quality measure reporting: AWVs offer an opportunity to address care gaps and report quality measures important in pay-for-performance systems.
Conclusion
Enhancing the completion rates of AWVs and CPEs is crucial for improving patient health outcomes and optimizing clinic performance. By completing these encounters, we can ensure that our patients receive comprehensive preventive care, while also meeting clinic's operational and financial goals.
Reminder: Observation vs inpatient admission prior authorizations (PA)
BCBSNE would like to remind providers of the following guidelines regarding MA PA:
Observation level of care: No prior PA submission is required for Observation level of care.
Inpatient admissions: PA is required for inpatient admissions.
Upgrading from Observation to inpatient: If a patient is upgraded from Observation to an inpatient level of care, please submit a PA request via NaviNet. Ensure that the Observation dates are included to bundle the Observation days with the Diagnosis-Related Group for claims and billing purposes.
Centers for Medicare & Medicaid (CMS) changes to Risk Adjustment Data Validation (RADV)
BCBSNE is committed to transparency and keeping our providers informed. We would like to notify you of significant changes and updates to the CMS RADV auditing process. Your support in providing medical records will be crucial as we navigate these changes.
Key update:
On May 21, 2025, CMS announced a dramatic expansion of its RADV audit program that will affect all MA plans. This represents the most significant change to RADV auditing in the program's history.
What's changed:
Annual audits: CMS will now audit all eligible MA contracts annually (previously about 60 contracts per year).
Increased sample sizes: Audit sample sizes will increase from 35 to up to 200 member records per contract.
Expedited completion: CMS is expediting the completion of all audits for Payment Years 2018-2024 by early 2026.
Expanded workforce: The agency is expanding its medical coder workforce from 40 to 2,000 coders by September 2025.
Enhanced technology: Enhanced AI technology will be deployed to identify potentially unsupported diagnoses.
Although these audits are on the MA Organization, upon request, BCBSNE will need your support in providing medical records.
Thank you for your continued partnership and cooperation.
We recently communicated a change in the management of certain specialty drugs under the medical benefit for MA members. This program is expanding to include our Commercial members. Beginning Sept. 30, 2025, providers should begin contacting Prime to obtain PA for the in-scope drugs for our Commercial members with dates of service on or after Sept. 30, 2025.
PA will be required for the medical specialty drugs for Commercial and Medicare members when they are administered in the following settings:
Physician Office (POS 11)
Patient Homes (POS 12)
Outpatient Facilities (POS 19, 22)
For routine requests and clinical guideline information please visit GatewayPA.com.
For urgent and expedited requests please call 800-424-1709.
Department of Corrections claims
The Department of Corrections has made a change to their member benefits that impacts the way claims are processed. Beginning Jan. 1, 2024, members whose ID numbers begin with 888 and are IP longer than 24 hours, could qualify for Medicaid.
If the member does qualify for Medicaid, the Department of Corrections will inform the provider of the Medicaid coverage. Claims submitted to BCBSNE for these members will deny as provider liability.
These claims will not be eligible for appeal or reconsideration. There is no need to contact Member Services or your Provider Partnership Advocate. Please direct questions about these denials to the Department of Corrections or Medicaid for eligibility information if needed.
Do you have a new team member who would like to be added to our email list?
They can sign up for Provider updates online in the same location as our Provider Updates newsletter on the Alerts and Updates page.
You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
NaviNet® is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and mail service company.
