Happening Now

For questions or support, providers have three options to connect with BCBSNE.

1. 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
2. If the issue is not resolved, submit a Provider Advanced Inquiry (PAI) using the Claims Investigation reference number to ensure proper routing
3. If online options aren’t viable, providers may also contact the Customer Support Center at 800‑635‑0579 for assistance

Effective Oct. 1, 2026, prior authorization will no longer be required for the first 20 home health care visits for members enrolled in commercial plans. This change streamlines the authorization process and supports timely access to care.

Home health care providers may deliver up to 20 visits without submitting a prior authorization request. Prior authorization will be required beginning with the 21st visit.

To ensure a smooth transition, providers should review and update their authorization workflows before the effective date.

Summary of changes

• Effective date: Oct. 1, 2026
• Applies to: Commercial plans
• No prior authorization required: Visits 1-20
• Prior authorization required: Beginning with visit 21

Effective Nov. 1, 2026, Blue Cross and Blue Shield of Nebraska (BCBSNE) will require prior authorization through Evolent™ for select joint surgery procedures. This represents a new prior authorization requirement for many providers.

To support this transition:

• A list of impacted procedure codes will be available in the September 2026 Provider Update Newsletter
• Provider should watch for future communications from BCBSNE and Evolent regarding implementation details, training materials and program resources
• On-demand training and educational resources will be available in the Evolent portal, RadMD prior to implementation
• Providers who are new to RadMD are encouraged to register for portal access to access program information, training materials and other resources available prior to program launch.

Please note: Prior authorizations approved by BCBSNE before Nov. 1, 2026, will be honored through their respective valid-through dates.

^{Evolent™ is an independent company that provides utilization management services through RadMD® for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.}

Blue Cross and Blue Shield of Nebraska (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.

Appeals and 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.

Blue Cross and Blue Shield of Nebraska is standardizing payer ID usage and claim acknowledgement processes to simplify electronic claims submission and improve consistency across Commercial, Dental and Medicare Advantage lines of business. Providers should continue working with their practice management system vendor or clearinghouse to ensure payer ID configurations are updated for the appropriate payer ID: 77780 for Commercial and Dental, A6492 for Medicare Advantage (as of Jan. 1, 2027).

Beginning Jan. 1, 2027, BCBSNE will also retire the Claim Confirmation Report and move to the standard ASC X12 277CA claim acknowledgement transaction for all trading partners. Additional details, including payer ID guidance, timing and readiness steps, are available in the August provider newsletter found in the Alerts & Updates for Providers page.

To help ensure inpatient surgical services are reviewed consistently and supported by appropriate clinical information, BCBSNE has updated the way inpatient surgical authorization requests are processed.

What's changed?

• Requests no longer receive immediate approval through the portal workflow
• Requests are routed to a nurse reviewer for clinical review before an authorization determination is made

What's stayed the same?

• Providers submit inpatient surgical authorization requests through the provider portal
• Authorization requirements remain unchanged
• Medical necessity criteria remain unchanged
• No additional action is required from providers at this time

What should providers expect?

• Requests that previously received immediate approval through the portal will now require clinical review before a determination is made
• Providers may be asked to submit clinical documentation to support the request
• This change is intended to improve review accuracy and help ensure services meet medical necessity requirements
• To help support timely review and determination of your request, include applicable surgical CPT codes in your notes and any submitted clinical documentation

Providers should continue submitting requests through the provider portal. BCBSNE will request additional clinical documentation when needed to support the review process. 

We're introducing a new Outpatient to Inpatient 3-Day Window policy effective Sept. 15, 2026. This policy applies to facility claims and provides guidance on reimbursement for preadmission and preoperative services. Review the policy for complete details and requirements.

View the full policy. 

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 supported by Medicare policy, client medical policies, and nationally recognized clinical and billing guidelines. It is designed to complement existing prior authorization and concurrent review activities, reinforcing appropriate admission decisions while minimizing unnecessary disruption.

Reviews are conducted by Cotiviti’s experienced registered nurses, with physician oversight, leveraging deep expertise in clinical documentation, utilization management, and claims accuracy.

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.