Provider Update November 2025

Medicare Advantage

MA 2024 Claims Timeout Notification

As of Jan. 1, 2025, all Medicare Advantage (MA) program operations transitioned fully in-house from Advantasure. The final step in this transition is the closure of all remaining 2024 claims. Claims with dates of service on or before Dec. 31, 2024 are no longer eligible for reconsideration or adjustment as of Jan. 1, 2026.

If you wish to appeal or dispute a 2024 claim, please submit your request as soon as possible to the contact information below:

Blue Cross and Blue Shield of Nebraska
PO Box 21831
Eagan, MN 55121
Fax: 1-877-482-9749

Please note that all clean MA claims must be submitted within 120 days of the date of service, or within the timeframe outlined in your provider agreement.

Beginning Jan. 1, 2026, no adjustments will be accepted for claims with 2024 dates of service—no exceptions. Any claims submitted after Dec. 31, 2025 will be rejected for timely filing. To avoid issues, please ensure all corrections are submitted as early as possible.

Billing Guidance for HCPCS Modifiers GA, GX, GY and GZ

Effective Nov. 1, 2025, BCBSNE Medicare Advantage is implementing updated billing guidance for the use of HCPCS modifiers GA, GX, GY and GZ. These modifiers support accurate claims processing and help determine appropriate member or provider liability.

This new policy was effective Nov. 1, 2025, and will be available for review prior to the effective date.

Please refer to Section 10.2, Chapter 4 of the Medicare Managed Care Manual for additional context on billing and payment rules that may differ from Original Medicare.

Modifier Usage and Outcomes

• GA – Pre-Service Notice of Non-Coverage Provided
  • Use when an ABN is on file for services expected to be denied due to lack of medical necessity.
  • May be appended to specific or miscellaneous HCPCS codes.
  • Outcome: Claim is member liability. You may bill the member.
  • Note: If a non-covered service is billed without a GA modifier, the claim will be denied and assigned to provider liability.
• GZ – No Notice of Non-Coverage Provided
  • Use when services are expected to be denied and no ABN was issued.
  • Outcome: Claim is provider liability. You may not bill the member.
• GX – Not Required
  • Use for statutorily non-covered services submitted with non-covered charges only.
  • May be used in combination with the GY modifier.
  • Outcome: Claim is provider liability.
• GY – Statutorily Excluded Services
  • Use when the item/service is excluded by statute and not a Medicare benefit.
  • Outcome: Claim is member liability. You may bill the member.
    

Providers are reminded to notify Medicare Advantage members of non-coverage when applicable and to apply the appropriate modifier(s) to ensure compliant billing.

Medical: Commercial and FEP

Upcoming changes to preferred biologic medications: Humira and Stelara (effective Jan. 1, 2026)

• Humira (adalimumab) and Stelara (ustekinumab)

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

• 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.

Peer-to-Peer Changes Effective Jan. 1, 2026

BCBSNE is updating our Peer-to-Peer procedure (GP-P-003) 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 the appeal process.

Medical Pharmacy Prior Authorization Update - NaviNet Access began on Oct. 16, 2025

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, effective 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)”. This link allows 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 – Began 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. 

Value-Based Care

The Benefit and Importance of Scheduling AWV/CPE Visits for 2026

As we begin 2026, it’s the perfect time to encourage patients to schedule their Annual Wellness Visits (AWV) and Comprehensive Physical Exams (CPEs). These visits are key opportunities to strengthen the provider–patient relationship, promote preventive care, and improve health outcomes across our patient population.
 
Promotes Early Detection and Preventive Care
AWV/CPE visits allow providers to identify risk factors, detect early signs of chronic conditions, and update necessary screenings and immunizations. Early intervention not only improves quality of life but also reduces the cost and complexity of managing advanced disease.
 
Supports Risk Adjustment and Accurate Documentation
These visits provide a dedicated time to review the patient’s complete medical history, update the problem list, and ensure all chronic conditions are accurately captured and documented. Comprehensive documentation supports appropriate risk adjustment, ensures patients receive care aligned with their true health status, and contributes to accurate reimbursement.
 
Strengthens Patient Engagement
Regular preventive visits reinforce the importance of proactive healthcare. Patients who consistently attend their AWV/CPE are more likely to follow care plans, adhere to medications, and participate in shared decision-making. This engagement leads to improved satisfaction and long-term outcomes.
 
Aligns with Quality and Value-Based Goals
Scheduling and completing AWV/CPE visits early in the year allows practices to meet quality performance measures and ensure compliance with value-based care initiatives. Early scheduling also helps balance clinic workloads throughout the year and reduces end-of-year pressure.
 
Encourages a Whole-Person Approach
Beyond physical health, these visits provide a platform to address mental well-being, social determinants of health, lifestyle habits and preventive counseling. Providers can tailor care plans to support the patient’s holistic needs.
 
Covered Benefit for Members
Annual Wellness Visits and Comprehensive Physical Exams are covered benefits for Blue Cross Blue Shield of Nebraska members. Encouraging patients to take advantage of this benefit supports preventive health, closes care gaps, and helps ensure members receive the care they deserve at no additional cost to them when billed appropriately.
 
Key Takeaway:
Encourage your patients to schedule their AWV or CPE early in 2026. These visits are not just check-ups; they are essential tools for prevention, documentation accuracy and the overall improvement of patient health outcomes.