Provider FAQs

Many MA plans have low out-of-pocket costs and premiums. In many plans, hospitals and providers are paid the same as Original Medicare. MA plans place an emphasis on preventive care and include many benefits not offered by Original Medicare, which have been shown to improve the health and well-being of MA members compared to Original Medicare.

Again, not all MA plans are created equal. Many MA plans do not require referrals to see specialists. MA plans may require prior authorization for some services to ensure the care is medically necessary and the proper payments are made. Many of these controls do not exist in Original Medicare, making healthcare more expensive overall.

Yes, new cards have begun going out but are NOT effective until 1/1/25.

• YMA4 will be the new prefix for the HMO product instead of YMAN.
• Y2M4 will be the new prefix for the PPO product instead of Y2MN.

Yes, just like our commercial BCBSNE members, the BCBSNE MA member cards will be available on NaviNet.

All MA plans are not the same. Each MA plan is customized by private health insurance companies and follow guidelines provided by the federal government. Most MA plans offer benefits beyond Original Medicare.

Many MA plans provide care using networks of providers and specialists, but all networks are not equal. PPO MA plans allow you to use doctors, hospitals and other healthcare providers outside the network without a referral.

Many MA plans offer robust travel networks of providers allowing flexibility across the country.

Original Medicare does not pay for the entire cost of care, so costs are passed to the beneficiary. Many MA plans include predictable cost-share amounts in the form of copays or coinsurance for covered Medicare services, which are applicable toward an annual maximum out-of-pocket amount. Original Medicare does not offer the same financial protection.

MA plan benefits can change annually. The Annual Enrollment Period (AEP), which runs from Oct. 15 to Dec. 7 each year, is an opportunity for Medicare beneficiaries to evaluate their plan and determine if changes are necessary for the upcoming year.

Yes, we recently communicated a change in the management of certain drugs under the medical benefit for Medicare Advantage (MA) members. The prior authorization requests can be submitted via web exclusively through the P3 Provider Portal via NaviNet. The MA Part B drug request form has been retired and you will no longer be able to submit these prior authorizations via fax.

Thank you for your continued support in ensuring our members receive high-quality and clinically appropriate care.

Yes, NaviNet will guide providers to the appropriate prior authorization workflow based on the line of business.

Effective May 1, 2026, all MA medical and medical pharmacy prior authorization requests must be submitted through the P3 Provider Portal. 

Providers will continue to access prior authorizations through single sign-on (SSO) from NaviNet, which now includes two distinct options: 

• Commercial Prior Authorization 
• Medicare Advantage Prior Authorization 

Selecting Medicare Advantage Prior Authorization will route providers directly into the P3 Provider Portal to submit and manage all MA prior authorization requests. 

The following MA prior authorization requests are included in the P3 Provider Portal:

• Medical Prior Authorizations, including inpatient admissions 
• Musculoskeletal (MSK) and Interventional Pain Management (IPM) requests  
  
  • Previously submitted through Evolent 
• Medical Pharmacy prior authorizations for Medicare Advantage Part B medications  
  
  • Previously submitted through OptimizeRx via the GatewayPA portal 

All of these request types will now be submitted and tracked within P3, providing a single, centralized MA authorization workflow. 

An eLearning module is available to guide providers on submitting requests, searching existing authorizations, and uploading medical records in the P3 portal. 

Prior authorizations will carry over as part of the P3 Health transition effective May 1, 2026. A new authorization is not required solely because dates of service extend into May 2026. 

Effective immediately, open inpatient MA authorizations have transitioned to P3 Health for completion. 

• Authorizations opened prior to May 1, 2026 
  
  • For open inpatient MA authorizations these have been transferred to P3 Health and are being closed by BCBSNE, with P3 Health now responsible for completing all remaining processing. 
  • For all other authorizations continue to check the status in the same system where the request was originally submitted, such as NaviNet® or the applicable authorization portal. 
• Authorizations submitted on or after May 1, 2026 
  
  • Status should be checked in the P3 Provider Portal, which is accessible via NaviNet single sign-on (SSO) once live. 

If you contact BCBSNE with questions regarding an open inpatient authorization submitted prior to May 1, 2026, BCBSNE teams will reference the pre‑transition authorization list and redirect providers to P3 Health as appropriate. 

No action is needed from providers at this time. P3 Health will handle all remaining activity for transferred authorizations, including those with dates of service extending beyond May 1, 2026. g existing authorizations, and uploading medical records in the P3 portal. 

Yes. An authorization can be submitted, but it’s important to include clinical documentation. P3 Health Utilization Management (UM) will complete the review. 

No. Once submitted, an authorization cannot be amended; however, additional clinical documentation may be added.

No. There is no draft‑saving feature available.

Each denial will include specific instructions for peer‑to‑peer review and appeals.

No. Backdating authorizations is not allowed.

Yes. BCBSNE will continue to conduct retro reviews.

If you are the PCP, even if you did not initiate the preauthorization, you will receive the decision from P3 Health as the members PCP.

P3 primarily requests clinical updates through the portal.

• Submit updated clinicals every 3 days.
• Attach documentation to the existing authorization.
• Avoid duplicate submissions to prevent delays.

You will only be able to view a preauthorization in the P3 portal if you are listed as the submitter, requesting provider or servicing provider on the authorization. When listed in one of these roles, you can locate the authorization by using the Search tab in the Auth Center within the P3 portal. 

If you are not listed as the requesting provider or servicing provider on the submitted preauthorization, you will not be able to view it in the P3 portal.  

If you need information about a preauthorization submitted by another provider, please contact the ordering provider directly, as they can share the relevant details with you.

P3 authorization numbers are 20-digit numeric values.

This is not necessary; the IP admission request should be made the day the member is admitted inpatient for a planned procedure and will be reviewed based on clinical documentation.

No.

P3 reviews the request as a whole; however, inpatient days may not be approved in advance if medical necessity cannot be confirmed prior to the procedure.

Not necessarily. It could also mean the case is still under review.

If inpatient days are not approved in advance, the facility should submit a separate facility concurrent review authorization request if an inpatient stay becomes necessary after the procedure.

A separate concurrent reivew authorization should be submitted: 

• Within 24 hours after the procedure has occurred.
• When it is determined that the member requires an inpatient stay.

P3 will review the full clinical scenario. In some cases, inpatient days may be approved with the initial authorization; however, approval is based on medical necessity at the time of review.

A Notice of Admission (NOA) should be submitted within 24 hours of admission.

Additional submission details are available in the portal under the “Hospital” section.

No. Providers do not need to request bed days. Bed days are managed as part of the concurrent review process based on the clinical presentation of the patient and documentation.

No. Observation notifications are not required in accordance with current BCBSNE policy and procedures.

Yes. Members can be searched in the P3 Portal using one of the following: 

• Member name 
• Member ID 
• Date of birth (DOB) 

When searching by Member ID, please note:

• Do not include the alpha prefix.
• The Member ID must include the two-digit suffix “00” at the end.

No. Providers are not required to complete a medical necessity review when submitting an authorization. 

All medical necessity reviews are conducted by the P3 Utilization Management (UM) team using the CMS Hierarchy (NCD/LCD/HP Criteria/MCG criteria).

When completing a Medicare Advantage (MA) prior authorization request in the P3 Provider Portal, the Requesting or Servicing Provider sections will automatically populate with the provider’s default address after searching by NPI or TIN.

If the default address is not correct, select “Change Location” under the provider information to view and choose from available addresses associated with the provider’s NPI/TIN, then confirm your selection. The updated address will populate in the request.

Note: Only addresses linked to the provider’s NPI/TIN will be available for selection.

If you are experiencing issues submitting an authorization through the portal, the fastest way to ensure timely processing is to fax the request using the Medicare Advantage Authorization Form, available on the MA Forms page. Please send the completed form, all required clinical documentation and a brief note describing the portal issue to the fax number listed on the form. For additional assistance, you may also contact P3 at umanagement@p3hp.org.

Select Concurrent Review as the authorization type. Priority should be Standard.

The requesting provider should be the provider at the submitting facility. The servicing provider and service facility should be the SNF receiving the patient.

Example: If a patient is in the hospital, the hospital is the requesting provider and the receiving SNF is the servicing provider/facility.

 Upload clinical documentation directly to the authorization in the portal at the time of submission.

• Submit updated clinicals approximately every 3 days by attaching records to the existing authorization.
• Do not submit new authorization requests to request additional days.
• Avoid submitting duplicate updates for the same time period, as this may create duplicate cases and delays.

If submitted through the portal, it should appear once processed.

If information is faxed, P3 advised allowing at least 24 hours for the care navigation team to build the case before it is fully visible in the Auth Center.

An initial review letter is issued but continued-stay approvals are generally reflected in the portal rather than through repeated approval letters. Users should review the authorization details in the Auth Center for the most current status and any extension of approved dates.

When the patient no longer appears to meet criteria, the P3 team will notify the facility and begin the NOMNC-related process. The NOMNC will be faxed to the facility for the provider to administer to the member. NOMNC should be faxed back to P3 reviewer (nurse who sent the NOMNC/DENC).

The first point of contact is the concurrent review nurse assigned to the case, whose name should be visible in the authorization determination fax to the provider. General utilization management questions may also be routed through the P3 email contact, UManagement@p3hp.org.

Typically, yes. P3 strives to maintain consistent nurse assignments by facility, though coverage may vary.

You will be able to view an authorization in the P3 portal if you are listed as the submitter, requesting provider or servicing provider on the authorization. When listed in one of these roles, you can locate the authorization by using the Search tab in the Auth Center within the P3 portal. Best practice is to use member name, DOB or Member ID.

If you are not listed as the requesting provider, or servicing provider on the submitted preauthorization, you will not be able to view it in the P3 portal.

If you need information about an authorization submitted by another provider, please contact the ordering provider directly, as they can share the relevant details with you.

No, the payer ID will not change.

Reimbursement is based on your CMS percentage, and we will not be posting the fee schedules. You may access the CMS fee schedules at cms.gov.