Optional H2 Subhead
Provider Update May 2026
Jump to section:General information | Medicare Advantage | Medical: Commercial and FEP | Quality and Risk | Security Corner
Welcome to your Provider Update Newsletter, bringing together important updates for our medical, dental and Medicare Advantage products in one convenient publication.
General information
Final issue of Provider Bulletin
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 on NaviNet.
Ongoing provider communications
Providers can continue to rely on two primary sources for ongoing communications:
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.
NaviNet®
NaviNet continues to serve as the primary source for real-time communications. Providers can use NaviNet to view announcements, receive secure messages, access forms and policies and stay informed about changes that may affect their practice. Communication is available without waiting for a scheduled publication. We will be transitioning away from Happening Now with two exceptions:
- Medicare Advantage communications
- Communications required for all providers, regardless of network status
Providers are encouraged to:
- Review the monthly Provider UPDATE newsletter for ongoing updates and reminders
- Log in to NaviNet regularly for announcements and time-sensitive information
- Use NaviNet 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.
Effective June 1, 2026: Short stay and clinical chart validation reviews
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 grounded in Medicare policy, applicable medical policies and nationally recognized clinical and billing guidelines. It is intended to work alongside existing prior authorization and concurrent review processes, helping support consistent admission decisions while reducing unnecessary disruption for providers whenever possible.
Reviews are completed by Cotiviti’s experienced registered nurses, with physician oversight, bringing clinical expertise in documentation, utilization management and claims review. Their role is to support a thoughtful, consistent review process aligned with established standards.
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.
How to Contact BCBSNE
For questions or support, providers have three options to connect with BCBSNE:
- 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
- If the issue is not resolved, submit a Provider Advanced Inquiry (PAI) using the Claims Investigation reference number to ensure proper routing
- If online options aren’t viable, providers may also contact the Customer Support Center at 800-635-0579 for assistance
Medicare Advantage
Medicare Advantage (MA) Prior Authorization Update with P3 Health
May 1, 2026, BCBSNE implemented important updates to Medicare Advantage (MA) prior authorization processes in partnership with P3 Health. These changes are designed to enhance care coordination and improve administrative efficiency while maintaining continuity for members and providers.
P3 Provider Portal Now Live for MA Authorizations
All MA medical and medical pharmacy prior authorization requests must now be submitted through the P3 Provider Portal.
Providers can access the portal via single sign on (SSO) through NaviNet by selecting:
- Medicare Advantage Prior Authorization
This will route you directly into the P3 portal to:
- Submit authorization requests
- Search for existing authorizations
- Upload medical records
An eLearning module is available to guide providers on submitting requests, searching existing authorizations and uploading medical records in the P3 portal.
Inpatient Authorizations Transitioned to P3 Health
As of May 1, 2026:
- Open inpatient MA authorizations initiated prior to May 1, 2026 have been transitioned to P3 Health
- These authorizations are being closed by BCBSNE, with P3 Health now responsible for continued processing
If you contact BCBSNE regarding these cases, teams will reference pre transition records and direct you to P3 Health as appropriate.
No action is required from providers for transitioned authorizations.
Authorization Access and Status
- Authorizations submitted on or after May 1, 2026: View status in the P3 Provider Portal
- Authorizations submitted prior to May 1, 2026: Remain available in NaviNet
- Authorization decisions will continue to be communicated via fax
- Existing phone and fax numbers remain unchanged unless otherwise communicated
Authorization Turnaround Time (TAT)
Authorization TAT begins only after:
- Portal access has been successfully established, and
- A complete authorization request has been submitted.
Standard MA authorization TATs include:
- Urgent requests: 72 hours
- General requests: 7 calendar days
- Part B Drug Standard: 72 hours
- Part B Drug Expedited: 24 hours
Medicare Advantage Expedited Requests: If a request is made or supported by a physician, prescribing physician or other prescriber who indicates that applying the standard timeframe could seriously jeopardize the life or health of the enrollee, or the enrollee’s ability to regain maximum function.
Temporary Changes to Automated Approvals
During the transition period:
- Real time automated approvals may be limited throughout May 2026
- Requests may require manual review, which can impact immediate decisioning
Beginning June 1, 2026, P3 Health will introduce enhanced automation to support real time approvals, where applicable.
No action is required from providers.
Third party Vendor Access Reminder
Providers utilizing third party vendors (including offshore teams) should note:
- Access to the P3 Provider Portal follows the same security requirements as NaviNet
- Vendors without appropriate U.S.-based access may be unable to log in
Providers are encouraged to review the Preauthorization FAQ for full details and guidance on third party and offshore vendor access considerations.
Stay Informed
Updates will continue to be posted on NebraskaBlue – MA Happening Now, as needed, and will focus on new or updated information only. Providers are encouraged to check back regularly as additional details are shared ahead of the 2026 implementation.
MA CAH Cost Settlement and Bad Debt Hospital Settlement Update
On April 30, 2026, we announced through both Medicare Advantage Happening Now and NaviNet that, to support long-term stability and alignment with CMS Medicare Advantage (MA) guidelines, BCBSNE and our new MA partner, P3 Health*, completed a review of current hospital settlement processes. As a result, effective July 1, 2026, the following MA settlement processes for in network providers will be retired:
- MA Critical Access Hospital Cost Settlement for In-Network Providers
- MA Bad Debt Hospital Settlement for In-Network Providers
Through this joint review, BCBSNE and P3 Health assessed current CMS guidance and MA payment design and have determined that these settlement processes are not required. CMS does not require MA plans to replicate Original Medicare’s retrospective cost settlement or bad debt reimbursement processes. MA payments are designed to be prospective and contract-based, providing predictability for providers and members.
What this change means for you:
- Claims will continue to be paid according to your contracted MA rates
- Reimbursement will remain consistent, timely and predictable
This update supports a sustainable MA program while continuing our commitment to providing stable reimbursement to our provider partners and supporting access to high-quality care for our members.
* About our new MA partner: P3 Health is a physician-led organization that specializes in Medicare Advantage. They bring hands-on clinical expertise and experience in supporting providers in value-based care. Our partnership with them combines BCBSNE’s strong 87-year track record with the specialized expertise of P3 Health to continue to offer Nebraskans an affordable, high value Medicare Advantage plan.
Medical: Commercial and FEP
Correction to Nov. 17, 2025, preauthorization article
This notice was posted on Happening Now on April 17, 2026, to correct information in “Preauthorization submissions transitioned to digital-only on November 17, 2025.” Fax numbers referenced in that article are not used for preauthorization or pre-certification requests.
Effective Nov. 17, 2025, Commercial and Federal Employee Program preauthorization and pre-certification requests must be submitted digitally through NaviNet or the universal preauthorization request form for out-of-network and out-of-state providers. Faxed requests will not be accepted or processed.
For commercial preauthorization requests submitted through the Universal PA Request form, all medical records and required documentation must be uploaded online at the time of submission, including medical records, clinical notes and supporting information.
Submitting all materials together helps support faster review and reduces administrative delays. If a request was originally submitted through NaviNet, any additional documentation must be uploaded directly in NaviNet, not through the Universal PA Request form.
Fax numbers should not be used for preauthorization or pre-certification submissions.
Visit Provider Academy for resources and FAQs.
Update: Enhanced NICU Support with ProgenyHealth, beginning May 4, 2026
BCBSNE is pleased to announce a partnership with ProgenyHealth, a company specializing in Neonatal Care Management Services. This partnership enhances services for our members and supports our mission to make a lasting difference in our members’ lives by improving their health and well-being.
Under the agreement beginning May 4, 2026, ProgenyHealth’s Neonatologists, Pediatricians and Neonatal Nurse Care Managers will work closely with BCBSNE members, as well as attending physicians and hospital staff, to promote healthy outcomes for premature and medically complex newborns.
The benefits of this partnership to you
- Support from a specialized team experienced in the complexity and stress of caring for infants in the NICU.
- A collaborative and proactive care management approach that supports timely and safe discharge to home.
- A partner committed to sharing best practices and working with NICUs nationwide to improve neonatal outcomes.
Families will have a dedicated case manager who provides education and support throughout the program, as well as access to an on-call clinical team available 24/7. For hospitals, ProgenyHealth will also serve as a liaison for BCBSNE by providing inpatient review services and assisting with discharge planning to ensure a smooth transition to the home setting.
Member identification and eligibility verification in NaviNet
Providers should begin by accessing NaviNet to locate and review the member’s information.
Access the member in NaviNet
- Log in to NaviNet.
- Search for the subscriber/member using available demographic information.
- A newborn most likely has not yet been added to the plan; however, using subscriber information allows providers to view how benefits apply under the policy.
- Navigate to the Benefits and Eligibility section.
Review newborn eligibility and 31-day coverage
If the newborn is not yet added to the plan, providers must determine whether the newborn is eligible for free automatic 31 day coverage, which allows the newborn to be automatically loaded to the plan.
- This information is available on the subscriber/member’s Benefits and Eligibility page in NaviNet.
- The page will indicate:
- Whether the newborn qualifies for automatic 31 day coverage, or
- Whether the newborn must be formally added to the plan by the employer group.
- This eligibility determination should be confirmed before proceeding with notification or authorization submissions.
Identifying ProgenyHealth program enrollment
Once eligibility is confirmed, providers must determine whether the member is enrolled in the ProgenyHealth program.
- ProgenyHealth enrollment status is displayed in the Benefits and Eligibility section in NaviNet when a member is in session.
- Review this section to confirm whether ProgenyHealth care management applies.
- This step is critical, as notification and authorization workflows differ based on ProgenyHealth enrollment.
Notification and authorization submission guidance
If the member Is enrolled in the ProgenyHealth program Effective May 4, 2026, providers must notify ProgenyHealth directly of:
- NICU admissions, or
- Admissions to special care nurseries related to NICU-level services.
Notifications should be submitted via fax at 800 540 9492. ProgenyHealth clinical staff will contact your designated hospital staff to provide utilization management and discharge planning support throughout the inpatient stay.
Important ProgenyHealth guidance
- If an infant is admitted to the NICU at birth and managed by ProgenyHealth, any subsequent NICU-related admissions during the first year of life should continue to be directed to ProgenyHealth.
If the member Is not enrolled in ProgenyHealth
- Follow standard BCBSNE notification and utilization management processes.
- If the member cannot be located in NaviNet after eligibility review, submit a Universal Prior Authorization (PA) Request Form.
Important:
If a Universal PA Request Form is submitted for a member who is enrolled in the ProgenyHealth program, the request will not continue through BCBSNE and the provider will be redirected to submit the notification directly to ProgenyHealth.
Special guidance for children under one year of age
- A child under one (1) year of age who was not admitted to the NICU at birth, regardless of whether ProgenyHealth applies, will be managed by BCBSNE using standard processes.
Retrospective payment validation and assurance (PVA)
Beginning June 1, 2026, ProgenyHealth will perform retrospective payment validation and assurance (PVA) on previously paid claims that are within a two-year lookback period, or a period in line with applicable BCBSNE provider contracts.
- Retrospective PVA will apply only to claims associated with NICU admissions that occurred prior to the ProgenyHealth go-live date of May 4, 2026.
If you wish to learn more about ProgenyHealth’s programs and services, visit ProgenyHealth. Thank you for your partnership in caring for BCBSNE members.
State of Nebraska members return July 1, 2026
Blue Cross and Blue Shield of Nebraska is excited to welcome approximately 28,000 State of Nebraska employees and their dependents back to BCBSNE for medical and pharmacy coverage effective July 1, 2026.
Here are sample member ID cards. The plan is identified by the network name displayed on the front of each card.
Members will have access to NEtwork BLUE, Premier Select BlueChoice or BluePrint Health, offering strong statewide access and continuity of care. Please review each member’s ID card at every visit to confirm network and benefits. Providers can quickly check participation at NebraskaBlue.com/Doctor-Finder.
Prescription drug coverage follows the Broad Network C formulary.
Members will also benefit from value-added programs that support whole-person health, including Virta Health for diabetes care, Progeny Health for maternity and NICU support, Hinge Health for virtual physical therapy and nurse-supported programs that help members manage ongoing health needs.
Thank you for your partnership in delivering a positive, seamless experience for these returning members.
Quality and Risk
Risk adjustment data validation audit
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.
BCBSNE will begin the process of retrieving medical records in June.
Under the terms of your contract with us, health care 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.
Security Corner
Phishing—Still the #1 Way Attackers Get In
Phishing emails remain the most common way hackers gain access to patient data in healthcare. In fact, a recent HHS Office for Civil Rights (OCR) enforcement action this February involved a substance use disorder treatment center that was breached after a single employee clicked a phishing link — compromising nearly 2,000 patient records. The lesson for providers: slow down before clicking links or opening attachments in unexpected emails, even if they appear to come from a colleague or trusted organization. When in doubt, verify the sender through a separate channel. One click is all it takes.