Expanding access to streamlined preauthorization and sunsetting the Gold Carding Program
To enhance the provider experience and ensure faster, more consistent access to care decisions, Blue Cross and Blue Shield of Nebraska (BCBSNE) is expanding access to real-time medical preauthorization through our provider portal. This improvement will allow all Participating (PAR) providers to benefit from immediate approvals when requests meet InterQual® criteria or BCBSNE medical policy.
As part of this transition, and in alignment with the Transparency in Prior Authorization Act, BCBSNE will sunset the current Gold Carding Program effective Jan. 1, 2026.
What’s changing:
Gold Carding Program ends: Jan. 1, 2026
New submission process: All PAR providers will submit medical preauthorization requests through the BCBSNE provider portal
Expanded access to immediate approvals: Requests that meet InterQual criteria or BCBSNE medical policy may be approved immediately, bringing automation and transparency to all PAR providers
Why this matters:
Equity across the network: All providers will follow the same streamlined process, eliminating variability and improving fairness
Faster turnaround: Real-time decisions help reduce administrative slowdowns
Greater transparency: Providers can see the criteria used for approvals, supporting more predictable outcomes
Regulatory alignment: This change supports compliance with new Nebraska legislation (LB77) while enhancing the provider experience
We appreciate your continued partnership and your commitment to delivering high-quality care to our members.
Final reminder: Transition to electronic remittance advices and payments
As part of BCBSNE’s continued efforts to streamline operations and reduce paper usage, we are reminding all providers that the transition to electronic remittance advices and payments is rapidly approaching. The deadline is Oct. 1, 2025 — action is required now to avoid disruptions.
Paper remittance advices will be discontinued effective Oct. 1, 2025. Providers must begin receiving 835s through a clearinghouse or by accessing remittance advices in NaviNet®.
Paper checks will no longer be an option after Oct. 1, 2025. Providers currently receiving paper checks must complete the electronic funds transfer (EFT) form to continue receiving payments.
Forms are available on NaviNet. Visit the Administrative Updates/Secure Forms section to access the necessary forms for EFT and electronic remittance advice enrollment. Please complete these steps as soon as possible.
Dentist exception: Dentists who are unable to enroll with a clearinghouse may continue receiving paper remittance advices due to limited self-service options in NaviNet.
Time is running out: Providers who do not complete the transition by the deadline may experience delays in payment and remittance delivery.
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 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 (MA) 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.
Action needed: Preauthorization submissions transition to digital-only in November 2025
To streamline administrative workflows, improve processing timeliness and enhance overall care delivery efficiency, BCBSNE will transition to accepting preauthorization requests exclusively through our digital tools starting Nov. 17, 2025. This change applies to medical preauthorization for our commercial lines of business.
Participating providers are expected to use NaviNet, our provider portal, for their preauthorization submissions.
For out-of-network and providers outside of Nebraska, a new online form will be available beginning Nov. 1, 2025.
Continue monitoring Happening Now and our Provider Bulletin for updates
As part of this transition, we will be retiring the commercial preauthorization fax lines on Nov. 17, 2025:
Medical (Outpatient): 1-800-255-2838 or 402-392-4141
Radiology: 1-800-991-5644 or 402-982-8644
Commercial Pre-Cert (Inpatient): 800-821-4788/402-343-3444 and 1-866-422-5120
Note: If you submit faxes prior to the Nov. 17 transition, you will receive messaging on your fax response notifying you of the upcoming change.
Fax lines remaining unchanged for medical records:
Medical records for Appeals (submission of Appeals through the provider portal is preferred)
888-492-4944
402-548-4684
Medical records for Commercial
402-392-4111
800-991-7389
Important: These fax lines are for medical records only. If preauthorization requests are sent to these numbers, they will not be processed, and providers will receive a faxed response indicating the request was misrouted.
Note: MA providers are encouraged to continue using the provider portal. The retiring fax lines apply only to commercial lines of business. MA fax lines are not affected and will remain in use as usual.
We appreciate your partnership as we move toward more efficient, digital-first solutions to support you and your patients.
For help getting started, visit the NaviNet FAQs in the Provider Academy.
Upcoming changes to preferred biologic medications: Humira and Stelara (Effective Jan. 1, 2026)
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.
ERA form submission now available online — effective Sept. 15, 2025
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 faxed.
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.
Coverage clarification: MA EyeMed and BCBSNE refraction benefits
To ensure accurate billing and benefit coordination, please review the following guidance regarding MA refraction services under EyeMed and BCBSNE.
Refraction coverage
EyeMed’s routine vision benefits include a comprehensive eye exam, which covers:
A health and wellness component
A refraction
If the exam is deemed medical in nature, providers should bill the comprehensive eye exam to the member’s medical insurance.
Important: EyeMed does not cover refraction-only claims. These will be denied if submitted separately.
Claim submission guidance
Providers are not required to submit claims to both EyeMed and BCBSNE.
BCBSNE does not cover refraction under medical benefits
EyeMed denies refraction-only claims
Submitting to both carriers does not result in coverage and may lead to unnecessary administrative effort.
Diagnosis pointer requirements for professional MA claims
When submitting professional claims to MA plans, it is essential to ensure that each procedure code (CPT/HCPCS) is accurately linked to the appropriate diagnosis code that supports medical necessity. This linkage is accomplished through the use of diagnosis pointers.
Diagnosis pointers serve to connect the provider’s clinical assessment to the procedures performed. Each CPT code billed must be associated with at least one diagnosis code that justifies the service rendered. On the CMS-1500 claim form, this is done by referencing the diagnosis code(s) listed in Box 21 using numeric pointers (1–12) in Box 24E.
A minimum of one diagnosis pointer is required per CPT code.
A maximum of four diagnosis pointers may be assigned to each CPT code.
The diagnosis code(s) referenced must clearly support the medical necessity of the procedure, as outlined in applicable Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Failure to accurately link procedures to medically necessary diagnoses may result in claim denials or payment delays. Therefore, it is imperative that billing staff and providers ensure diagnosis pointers are correctly assigned and supported by documentation. Incorrect use of diagnosis pointers will necessitate submission of a corrected claim. Reconsideration requests are not appropriate in these cases.
Billing for anesthesia services: CMS modifier requirements
Accurate billing for anesthesia services is essential for compliance and reimbursement, particularly when submitting data to under Centers for Medicare & Medicaid Services (CMS) guidelines.
CMS requires that anesthesia modifiers be listed first in the claim data sequence. These modifiers include:
QZ – CRNA service without medical direction by a physician
AA – Anesthesia services performed personally by an anesthesiologist
QS – Monitored anesthesia care service
Following the anesthesia modifier, any physical status modifiers should be listed second. These typically include:
P1 – A normal healthy patient
P2 – A patient with mild systemic disease
P3 – A patient with severe systemic disease
(and others as applicable)
Proper sequencing ensures that claims are processed correctly and that providers are reimbursed appropriately. Failure to follow this order may result in claim rejections or delays.
For billing teams and providers, it's important to review internal systems and workflows to ensure that modifier sequencing aligns with CMS requirements.
Expanded authorization submission options begin Oct. 13
Earlier this month we announced on Happening Now an exciting update that will simplify the prior authorization process and improve the provider experience.
Effective Oct. 13, 2025, BCBSNE will expand the types of prior authorization requests that can be submitted through our online portal for commercial and ACA members. Participating (PAR) providers are required to use the portal for these submissions. These enhancements are already in place for MA members.
This update allows providers to submit all authorization types through the portal. When submitted requests meet applicable InterQual® criteria or medical policy requirements, they may receive immediate approval, helping reduce delays and streamline your workflow.
What’s changing?
Inpatient acute care
Requests for medical/surgical and mental health/substance use disorder (MH/SUD) services may receive immediate approval when criteria are met.
Post-acute MH/SUD care
Initial requests may be approved immediately.
Continued stay requests will be reviewed by a nurse.
Post-acute Med/Surg care
Services such as skilled nursing facility (SNF), long-term acute care (LTAC), rehabilitation and hospice will continue to require nurse review for all requests.
Outpatient services
Requests for Med/Surg and MH/SUD services that require prior authorization may also receive immediate approval when criteria are met.
Outpatient MH/SUD services requiring prior authorization as of Oct. 13, 2025:
Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation (TMS)
Neurofeedback
Applied behavior analysis (ABA) therapy
Urine drug testing
ECT and TMS may receive immediate approval when criteria are met.
Neurofeedback requests will continue to pend for nurse review.
BCBSNE is developing a custom process to allow immediate approvals for ABA therapy and urine drug testing based on medical policy requirements. This functionality is expected to be available by Jan. 1, 2026.
We’re excited about this positive step forward and the value it brings to our provider community. These enhancements are designed to save you time, streamline processes and help you focus on what matters most — caring for your patients.
CoverMyMeds enhances PA process — launching Nov. 18
Starting Nov. 18, BCBSNE is making it easier for providers to manage drug prior authorizations with the launch of CoverMyMeds.
What’s changing?
Real-time eligibility checks to confirm coverage before submitting
Electronic prior authorization 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 improving provider experience.
Important: Claims submission for Department of Corrections members with Medicaid eligibility
If inpatient hospital or inpatient professional claims for a Department of Corrections member are submitted to BCBSNE when they should have been directed to Medicaid, those claims will be denied. Appeals should not be submitted to BCBSNE, as we will uphold the original denial.
Reminder: Correct claims routing for Department of Corrections members
When a Department of Corrections member qualifies for Medicaid, only inpatient hospital and inpatient professional claims should be submitted to Medicaid. These members continue to have outpatient benefits through BCBSNE, and outpatient service claims should be sent to BCBSNE.
To determine whether inpatient claims should be submitted to Medicaid, check the member’s eligibility in NaviNet. If the “Hospital – Inpatient” category shows “Not Covered,” the inpatient hospital and professional claims should be directed to Medicaid.
If you have questions, please contact Provider Services.
Breast Cancer awareness: Know the signs, save lives
Breast cancer continues to be the most commonly diagnosed cancer among women in the United States. While it’s often associated with women, it’s important to remember that anyone with breast tissue — including men — can be affected.
Awareness and early detection remain powerful tools in the fight against breast cancer. When caught early and still localized, the five-year relative survival rate is about 99%, according to the American Cancer Society. Thanks to advances in screening technology, health care professionals are now able to detect breast cancer earlier, improving outcomes and saving lives.
Recognizing the signs and symptoms is key. Patients should be encouraged to seek medical attention if they notice:
A new lump or thickened area in the breast
Swelling or changes in breast shape or size
Skin dimpling or an orange peel texture
Nipple changes, such as inversion or discharge
Redness, flaking or scaling of the breast or nipple
Swollen lymph nodes near the collarbone or underarm
Another important factor is breast density. Women with dense breast tissue have a higher risk of developing breast cancer, and dense tissue can make it harder to detect abnormalities on a mammogram. Supplemental imaging — such as ultrasound or MRI — can help identify cancers that may be missed by mammography alone.
Annual mammograms starting at age 40 are recommended for women at average risk. For those with dense breasts or other risk factors, additional screening may be beneficial.
By raising awareness and encouraging regular screenings, providers can help patients take proactive steps toward early detection and better outcomes.
BCBSNE ends medical necessity reviews for MH/SUD outpatient visits beyond 90
As we announced earlier this month on Happening Now, BCBSNE has eliminated the requirement for medical necessity reviews beginning with the 91st outpatient visit for mental health and substance use disorder (MH/SUD) services in a calendar year.
Effective July 31, 2025, this change is intended to reduce administrative burden and support more streamlined care delivery for providers and patients.
Providers are encouraged to update their workflows and documentation to reflect this positive change.
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You are receiving this because you are identified as a provider for Blue Cross and Blue Shield of Nebraska.
InterQual is a registered trademark of McKesson Corporation and/or one of its subsidiaries, an independent company providing services for Blue Cross and Blue Shield of Nebraska.
NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.
EyeMed is an independent company that provides vision benefits to Blue Cross and Blue Shield of Nebraska.
CoverMyMeds is an independent platform used to submit prior authorization requests. Coverage decisions are made solely by Blue Cross and Blue Shield of Nebraska BCBSNE or its pharmacy benefit manager.
