Happening Now

As a follow-up to the payment cycle adjustments we announced last August and implemented on November 1, 2025, we want to provide additional clarity based on recent analysis and questions from our provider community.  

After further review, we recognize that some of our earlier communications may not have fully reflected how the new 21‑day payment cycle functions in practice. We appreciate the questions and concerns shared with us, and we want to ensure you have accurate expectations moving forward. 
 

What we need to clarify  
The weekly payment cycle is now driven by claims aging to at least 21 days from the date they are received. Because of this structure:  

• There is no single “catch‑up” payment under the new cadence.
• Weekly payment amounts will not return to pre-November 1 patterns, even as the alignment is complete. Payment amounts will naturally vary from week to week, depending on when submitted claims reach the 21‑day threshold.
• Month-end billing patterns may create one higher payment approximately three weeks later, followed by a lower payment the next week; this is to be expected. 

These patterns reflect the normal operation of a true rolling 21‑day payment cycle. 

Why you may be seeing variability 
Your weekly reimbursement totals may appear lower or inconsistent compared to pre-November 2025 cycles. The payment cycle is operating as intended, and the variability you see is likely caused by one or more of any of the following: 

• Change in business mix
• Fluctuating claim submission volumes
• Timing of when claims reach the 21‑day mark
• Typical month-end submission patterns
• Clearinghouse batching (weekly, bi‑weekly or monthly), which can delay the received date and shift when claims fall into a payment cycle.
• Because settlement transitioned from Thursdays to Mondays, claims processed late in the month could potentially settle in a different month.  

Key concepts about the 21‑day cycle

Payable release date

• The payable release date is the primary trigger determining when a claim can move into the payment cycle.
• If a payable release date is not set, the claim cannot be paid, regardless of how long it has been in the system.  

When a payable release date is set 
A payable release date is created only when: 

• The claim is in Final or Denied status.
• Claims in Needs Review or those sitting in a work basket do not generate a payable release date.  

Impact of the 21‑day rule 
If a claim remains unresolved past the 21‑day threshold: 

• The payable release date will not backdate.
• It will be set to the earliest available date after the 21 day mark, once the claim moves into Final or Denied status (generally the same date it reaches that status).  

End-of-Month Payments
For end‑of‑month payments, the last day of the month is the issue date, and settlement occurs four business days later.

Non‑Nebraska exceptions  
These claims have additional requirements before entering the payment cycle.  

Required conditions 

• The claim must be in Final or Denied status.
• The member’s plan status must be finalized and received by BCBSNE before a payable release date can be set. 

Only after these conditions are met can the claim move into the payment cycle.  

Payable release date rules for exceptions 

• No payable release date is created until the claim reaches BCBSNE.
• If the claim arrives after 21 days:
  
  • The payable release date will not backdate.
  • It will be set to the first available date after the 21‑day mark.

Our commitment to you 
We understand that changes to payment timing impact cash‑flow planning, and we are committed to answering your questions and providing transparent communication as you adjust to this change.  

We also have a payment cycle calendar example available on Provider Academy under the FAQs section titled Paid Claims. 

We value your partnership and your feedback.

If you have questions about specific payment weeks or need support understanding the timing of claim batches, our teams are here to assist you.

Beginning Feb. 26, 2026, pharmacy preauthorization decision letters will be available directly in CoverMyMeds (CMM) for requests decisioned on or after that date. This enhancement gives providers faster access to decision information within the platform they already use.

What to know

• Letters for requests decisioned before Feb. 26 will not appear in CMM
• BCBSNE will continue faxing all decision letters to the ordering physician’s fax number on record
• The BCBSNE preauthorization reference number can be found on the faxed decision letter or through our automated IVR phone system. Please use these resources before contacting Customer Service
• We continue to follow the standard 72‑hour turnaround time for peer‑to‑peer requests

As part of our ongoing effort to simplify processes and reduce administrative burden for providers, BCBSNE is excited to announce a significant update: Beginning March 3, 2026, prior authorization requirements for non‑contrast CT scans will be eliminated across both Medicare Advantage and Commercial lines of business.

This change supports a more seamless experience for members and providers and reflects our continued commitment to thoughtfully reimagining preauthorization.

Why This Matters

• Faster access to care: Providers can schedule non‑contrast CT scans without waiting for approval
• Reduced administrative work: Less time spent on submitting and managing authorizations
• Supports our long‑term vision: We continue to focus on improving processes and removing barriers where appropriate

Important Clarification
This change applies only to non‑contrast CT scans.
If a prior authorization request is submitted for:

• CT with AND without contrast, or
• CT with contrast,
  ➡️ These services will still require prior authorization and medical review.

Rollout Timeline

• Feb. 23: All non‑contrast CT PAs will be approved
• Feb. 26: Code removal begins
• March 2: System updates completed
• March 3: Go‑live - No prior authorization required for non‑contrast CT scans

BCBSNE medical policy for treating obstructive sleep apnea (OSA) includes oral appliances as one of several covered options. Sleep apnea treatment must be preauthorized for BCBSNE members or the claim will be denied as provider liability.

Because dentists are best qualified to evaluate a patient’s suitability for an oral appliance and complete dental impressions, BCBSNE provides specific billing and coding guidelines for these services.

Key points for providers

• Sleep apnea treatment requires preauthorization or the claim will be provider liability.
• Dentists must use CDT Dental Procedure Codes from the NEtwork BLUE dental fee schedule when submitting a medical claim.
• Oral sleep devices must be billed under E0486.
• E0486 includes:
  
  • Fitting
  • Adjustments
  • Any related services such as x-rays, impressions and morning aligners
• Related services should not be billed separately, as they are included in E0486.

The medical policy for sleep apnea treatment is VIII.8 “Medical management for obstructive sleep apnea,” available at MedicalPolicy.NebraskaBlue.com.

What’s Changing

• Patient account numbers will no longer be included on reconsideration or appeal letters
• Member ID prefixes will also be removed
• Letters will continue to include the claim number and member ID, which remain the required identifiers for processing

Why This Change Is Occurring

• These updates help streamline our systems
• This reduce the need for custom development for elements not aligned with standard claims processing

Beginning April 2026, we will align with our Medicare Advantage (MA) procedures regarding the number of reconsiderations allowed per claim.

Key Update

• A maximum of two (2) reconsideration requests will be accepted for any single claim.
• The determination issued after the second reconsideration is final and binding.
• No additional reconsideration requests beyond the second will be accepted, reviewed, or processed.
• Additionally, participating (PAR) providers must submit reconsiderations via NaviNet, paper submissions will not be accepted, reviewed, or processed.
• Reconsiderations of beyond two per single claim or those submitted via paper will not be accepted, reviewed, or processed on or after April 6, 2026.

This update ensures consistency in processing and supports timely resolution of provider claims. For full details, please refer to Policy GP‑X‑073.

A reminder that the Coordination of Benefits (COB) policy GP‑X‑009 was updated on December 19, 2025. This update clarifies that all providers, including Dental providers, must follow standard COB rules to determine which payer is primary.

What Providers Need to Know

• When BCBSNE is the primary payer:
  Benefits are determined as if no other plan provided coverage.
• When BCBSNE is the secondary payer:
  Benefits are determined after the primary plan has issued its benefit determination.
• Secondary payer impact:
  When acting as the secondary payer, BCBSNE may reduce benefits based on the primary plan’s benefit responsibility.
• More than one Blues Plan:
  File the claim with the primary Blue plan first; once processed, submit the secondary claim with a copy of the primary EOB.

Please ensure your teams are reviewing the updated policy and applying the COB rules accordingly.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is excited to announce an upcoming partnership with ProgenyHealth, a leader in Neonatal Care Management Services. Beginning May 4, 2026, ProgenyHealth will support BCBSNE in enhancing care for premature and medically complex newborns.

This collaboration will bring additional clinical expertise and streamlined care management to support providers, families and our smallest members.

As part of this transition, the process for notifying BCBSNE of NICU or special care nursery admissions will change starting May 4, 2026. Additional details and instructions will be shared closer to the launch date.

Thank you for your ongoing partnership in caring for BCBSNE members.

BCBSNE is committed to making processes easy and efficient for providers. The fastest and most reliable way to submit requests is through NaviNet, our secure online portal.
 
Please note:
Reconsiderations for PAR (participating) providers cannot be submitted by mail or fax. Requests sent by mail or fax will not be processed. To avoid delays, submit requests electronically via NaviNet.
 
For details and access to the form, visit our Provider Academy page, where you’ll find eLearnings and FAQs with guidance on correct submission options.

Thank you for your attention and collaboration as we implement this updated process.

Before presenting an Advanced Beneficiary Notice (ABN) to a member, providers must verify benefits with BCBSNE or the member’s plan. ABNs should not be used for services that are covered, as this can lead to unnecessary costs and member abrasion. Covered services vary by plan, so confirming benefits is essential before presenting an ABN.

When an ABN Is Required
An ABN or waiver must be signed before services are rendered if the service may be denied as not medically necessary, investigative, or not scientifically validated. Providers must also inform the member in writing of potential financial liability and estimated costs.

For Federal Employee Program (FEP) members, a signed ABN is mandatory. Documentation in medical records will not be accepted.

Balance Billing Is Prohibited
In-network providers cannot balance bill BCBSNE members for amounts beyond the BCBSNE allowance for covered services.

For complete details, review policy GP-X-006: Hold Harmless and Balance Billing.

Starting in March 2026, new medical policies will go into effect for both Commercial and Medicare Advantage plans. In Feb. 2026, revisions to existing medical policies will also take effect. To ensure a smooth transition and minimize any disruption to your current processes, please review the updated policies below.

MA New Polices Effective 3/1/26

Amniotic Membrane and Amniotic Fluid
Policy number: M.14
Summary: Amniotic membrane is covered for specific eye and wound conditions (e.g., diabetic ulcers, corneal ulcers), but amniotic fluid injections are not medically necessary for any indication. Only specific products will be allowed; all others will be considered non-covered on CMS (01/01/2026).

Benign Prostate Hyperplasia
Policy Number: M.29
Summary: Covers specific minimally invasive treatments for BPH—such as prostatic urethral lift (Urolift), water vapor therapy (Rezum), and transurethral waterjet ablation—when strict clinical criteria are met, while deeming other procedures (e.g., PAE, cryoablation, HIFU) not medically necessary.

Single Chamber and Dual Chamber Permanent Cardiac Pacemaker and Defibrillators
Policy Number: M.30
Summary: Covers permanent pacemakers for symptomatic bradycardia and implantable cardioverter defibrillators (ICDs) for specific high-risk cardiac conditions per CMS NCD criteria, while excluding reversible causes and non-indicated uses.

Electrophysiology Testing and Cardiac Ablation
Policy Number: M.31
Summary: Coverage for electrophysiology (EP) testing and cardiac ablation is based on InterQual criteria to determine medical necessity for diagnostic and therapeutic procedures.

Non-Coronary Vascular Stents
Policy Number: M.32
Summary: Coverage for non-coronary vascular stent procedures is based on CMS LCD criteria (L35998 and A57590) to determine medical necessity for vascular interventions.

Cardiac Catheterization
Policy Number: M.33
Summary: Covers right, left, or combined heart catheterization when clinically indicated for diagnosis or treatment planning of cardiac conditions, while excluding non-indicated uses such as routine angioplasty or electrophysiologic studies.

Orthognathic Surgery
Policy Number: M.34
Summary: Covers orthognathic surgery for correction of skeletal deformities causing functional impairment when strict clinical criteria are met, and for obstructive sleep apnea after failure of CPAP; excludes cosmetic indications and procedures lacking proven effectiveness.

Urinary Incontinence Treatment
Policy Number: M.35
Summary: Allows periurethral bulking agent injections for stress urinary incontinence meeting specific criteria, while deeming adjustable balloon continence devices and other non-proven treatments not medically necessary.

Non-invasive Cerebrovascular and Peripheral Arterial Vascular Studies
Policy Number: M.36
Summary: Coverage for non-invasive cerebrovascular and peripheral arterial vascular studies follows CMS LCD criteria (L35753, A57592, L35761, A57593) to determine medical necessity for diagnostic imaging.

Echocardiogram, Transthoracic (TTE) and Transesophageal (TEE)
Policy Number: M.37
Summary: Echocardiogram coverage is based on InterQual criteria, with PA required for TEE but not for TTE, ensuring appropriate use for cardiac evaluation.

Percutaneous Coronary Intervention (PCI)
Policy Number: M.38
Summary: PCI procedures are covered when meeting CMS LCD L34761 criteria for medical necessity in coronary artery disease treatment.

Category III Codes
Policy Number: M.39
Summary: Category III procedures are generally considered experimental or not medically necessary unless proven safe, effective, and consistent with accepted medical standards.

Physical Medicine and Rehabilitation
Policy Number: M.40
Summary: Continued physical therapy beyond 12 visits requires prior authorization and documentation showing functional improvement, medical necessity, and inability to perform therapy independently.

Prostate Rectal Spacers
Policy Number: M.41
Summary: Covers prostate rectal spacers (e.g., SpaceOAR) for patients with localized prostate cancer undergoing hypofractionated radiation therapy when strict clinical criteria are met; not medically necessary if criteria are not met.

MA Revised Policies effective 3/1/26

Bioengineered Skin and Soft Tissue Substitutes
Policy Number: M.3
Summary: Covers bioengineered skin substitutes for diabetic foot ulcers, venous leg ulcers, and certain reconstructive or burn indications when strict LCD criteria and approved product lists are met; all other uses and products are considered non-covered. Only specific products will be allowed; all others will be considered non-covered on CMS (01/01/2026).

MA Cosmetic and Reconstructive Surgery (Codes Added)
Policy Number: M.5
Summary: Adds new codes for cosmetic and reconstructive procedures; coverage follows NCD 250.5, NCD 140.2, and LCD 39051 criteria for medical necessity.

MA Cosmetic and Reconstructive Surgery (Tissue Transfer Flaps)
Policy Number: M.5
Summary: Adds tissue transfer flap codes; coverage determined using InterQual criteria for reconstructive surgery indications.

MA Radiology
Policy Number: M.13
Summary: Radiology procedures require PA and follow InterQual, NCD, and LCD criteria for specific codes, including nuclear medicine and advanced imaging.

MA Procedures Following NCD, LCD or InterQual
Policy Number: M.15
Summary: Adds genetic testing, behavioral therapy, and device codes; coverage based on NCD and LCD guidelines for medical necessity.

Evolent Joint Surgeries
Policy Number: (No M-number provided)
Summary: Joint surgery codes require prior authorization, managed by Evolent, for hip, knee, and shoulder procedures.

Commercial New Policies effective 3/9/26

Non‑Urgent Air Ambulance Transport
Policy Number: I.217
Summary: Requires preauthorization for planned air ambulance transfers and is covered only when the patient needs acute inpatient care unavailable at the originating facility, the nearest capable receiving facility is used, and no safer lower‑intensity transport option (ground or commercial air) is appropriate; transports for convenience are not medically necessary.

Commercial Revised Policies effective 2/15/26

Computed Tomography Angiography (CTA)
Policy Number: IV.62
Summary: The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography (75580) may be considered medically necessary to guide decisions about the use of invasive coronary angiography in individuals with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic disease). All other uses are considered investigational.

Bone Mineral Density Measurement
Policy Number: IV.78
Summary: Screening for osteoporosis using Quantitative Computed Tomography (QCT) (77078), Ultrasound Densitometry and/or Vertebral Fracture Densitometry (77085, 77086, 76777) are Investigational.

Amniotic Membrane and Amniotic Fluid
Policy Number: I.200
Summary: The use of amniotic membrane using the following products **(Affinity^®, AmnioBand^® Membrane, Biovance^®, EpiCord^®, EpiFix^®, Grafix™, NuShield^®) is considered scientifically validated for treating specific conditions. These include diabetic lower extremity ulcers, neurotrophic keratitis, corneal ulcers or melts, pterygium repair, Stevens-Johnson syndrome of the eye, persistent epithelial defects, and chronic venous ulcers that have not healed after more than four weeks of standard therapy.

Bioengineered Skin and Soft Tissue Substitutes
Policy Number: I.202
Summary: The use of bioengineered skin and soft tissue substitutes is considered scientifically validated for the following indications:
Breast reconstruction (including each of the following: AlloDerm^®, Cortiva^® [AlloMax™], DermACELL™, DermaMatrix™, FlexHD^®, FlexHD^® Pliable™) OR
Diabetic lower extremity ulcers (AlloPatch^®a, Apligraf^®, Dermagraft^®, Integra^® Omnigraft™ Dermal Regeneration Matrix (also known as Omnigraft™), and Integra Flowable Wound Matrix, mVASC^®, TheraSkin^®) OR
Venous insufficiency lower extremity ulcers (Apligraf^®, Oasis™ Wound Matrix) OR
Dystrophic epidermolysis bullosa (OrCel™ (for the treatment of mitten-hand deformity when standard wound therapy has failed and when provided in accordance with the humanitarian device exemption [HDE] specifications of the U.S. Food and Drug Administration [FDA]) OR
Second- or third-degree burns (Epicel^® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA), Integra^® Dermal Regeneration Template.

Oscillatory Devices for Respiratory Disorders
Policy Number: VII.35
Summary: High-frequency chest wall oscillation and oscillatory PEP devices are covered for cystic fibrosis, primary ciliary dyskinesia, and bronchiectasis; all other uses, including Volara device, are investigational.

Surgeries for Obstructive Sleep Apnea
Policy Number: III.62
Summary: Covers unilateral hypoglossal nerve stimulation (e.g., Inspire^®) for adults and adolescents with Down syndrome under strict clinical criteria; bilateral hypoglossal nerve stimulation (e.g., Genio Device) is considered investigational.
 

Notifications about medical policy updates can be found under the “Recent Updates” section on the Alerts and Updates page.