Provider Update July 2026

Medicare Advantage

It’s live: MA medical necessity criteria transition to MCG

BCBSNE has officially transitioned MA utilization management criteria from InterQual to MCG (Milliman Care Guidelines), effective June 1, 2026.

What’s changed

• MCG guidelines are now in use for all MA utilization management reviews
• InterQual is no longer applied for MA medical necessity determinations

Accessing MCG in NaviNet^®

• Navigate to the MA prior authorization workflow in NaviNet
• Select the MCG Health Client log In
• Additional access details are available under the resources section in NaviNet

Providers should now use MCG criteria to support medical necessity for MA prior authorization requests. Familiarity with these guidelines will help ensure efficient submissions and review processes.

Stellus Rx outreach for Medicare Advantage Part D gaps

BCBSNE would like to inform providers that Stellus Rx will be conducting outreach on behalf of P3 Health Partners to support Medicare Advantage Part D gap closure efforts.

What to expect
Stellus Rx will act as an extension of P3 Health Partners to help address medication adherence opportunities and support patients throughout their care journey. Outreach may include:

• Contacting patients with due or past-due prescription refills
• Reaching out to patients with identified medication gaps
• Answering medication-related questions or concerns
• Providing access to a pharmacist via phone or text (when referred by a provider)
• Notifying provider offices of patient concerns or potential care changes, as appropriate
• Stellus Rx may also conduct outreach on other Part D gaps, as appropriate

What this means for providers

• Patients may be contacted directly by Stellus Rx pharmacists or support team members
• Stellus Rx may coordinate with provider offices if follow-up or clinical input is needed
• This outreach is intended to improve medication adherence and overall patient outcomes

BCBSNE appreciates your partnership in supporting coordinated care and improving medication adherence for Medicare Advantage members.

PCPs may receive preauthorization decision faxes

Providers may receive preauthorization decision faxes from P3 Health even if they did not submit the request.

Primary care providers (PCPs) will receive the authorization decision as part of their role as the member’s PCP, regardless of which provider initiated the preauthorization.

No action is required if you are not the requesting provider. These communications are being shared for care coordination and awareness.

Submitting P3 SNF concurrent reviews for inpatient stays

BCBSNE is providing guidance to support accurate and timely submission of MA skilled nursing facility (SNF) concurrent reviews through the P3 portal. Following the process below will help reduce delays, prevent duplicate cases and ensure efficient review of continued stay requests.

When submitting a concurrent review, providers should select the appropriate authorization settings. The correct authorization type is concurrent review and the priority should remain standard. Selecting the correct options ensures the request is routed appropriately for review.

Clinical documentation plays a critical role in the review process. Providers should upload clinical documentation directly to the authorization at the time of the initial request within the portal. After submission, facilities are encouraged to proactively provide clinical updates approximately every three (3) days by attaching supporting medical records to the existing authorization.

To avoid processing delays and duplication:

• Do not submit a new authorization request to request additional days
• Do not submit multiple updates covering the same time period, as this may create duplicate cases or overload processing queues

Once a request is submitted, timing for case visibility will vary based on the submission method. Requests submitted through the portal will appear once processed. If documentation is submitted via fax, providers should allow at least 24 hours for the P3 Care Navigation team to build the case before it becomes fully visible in the Auth Center.

During the concurrent review process, facilities will be notified if a patient no longer appears to meet medical necessity criteria. In these situations, the P3 Care Navigation team will conduct outreach to the facility and begin the Notice of Medicare Non-Coverage (NOMNC) process, as appropriate.

Finally, it is important to correctly assign provider roles within the authorization to ensure proper routing and review. When completing the request:

• The requesting provider should be the provider at the submitting facility
• The servicing provider and servicing facility should reflect the SNF receiving the patient

Adhering to this guidance will support clear communication, minimize administrative burden and help ensure timely determinations for SNF concurrent reviews.

Refresher: updating provider information and access while working with P3 Health

We’re committed to keeping you informed as BCBSNE continues the transition of its Medicare Advantage business to P3 Health.
 
As part of this collaboration, P3 Health now supports prior authorization reviews and select clinical decision-making processes for our members. As the partnership expands across the full Medicare Advantage line of business, we will continue to provide updates along the way.
 
Updating fax numbers, TINs and provider information

If your organization needs to update key information, such as a fax number or TIN, these updates must be completed through your organization’s internal administrative process.

• Work with your designated internal administrator or office manager to submit and manage updates
• Ensure changes are reflected within your organization’s systems and submitted through the CAQH Provider Data Portal
• P3 Health does not manage provider demographic or credentialing updates
• When submitting authorization requests through the P3 portal, verify that the fax number is accurate to ensure communications are sent correctly during the update process 

If you are unsure who your Security Officer is, please check with your organization’s leadership or administrative team. Additional information on updating provider data is available through the CAQH Provider Data Portal.
 
We understand that transitions like this can create questions, and we appreciate your continued partnership as we work to keep processes clear and seamless. Your feedback helps us improve—please continue to share your experience so we can better support you and your patients.

Dental

Dental eligibility display in NaviNet

Providers may notice that when viewing members enrolled in dental only plans, NaviNet displays “no benefits” under the dental section on the eligibility tab. While this may be confusing, dental coverage is active and available to view.

At this time, the NaviNet eligibility tab reflects medical coverage only. For members with dental only coverage, dental benefits do not appear on the eligibility tab even when the member is enrolled.

To confirm dental coverage, please select the member’s schedule of benefits (SOB). The SOB accurately reflects active dental benefits and coverage details.

This display limitation does not affect the member’s coverage. Providers should continue using the SOB to verify dental benefits when seeing dental only members in NaviNet.

We appreciate your continued partnership and your commitment to delivering excellent care.