Happening Now

BCBSNE is proud to welcome State of Nebraska employees and their dependents back beginning July 1, 2026, bringing approximately 28,000 members into BCBSNE medical and pharmacy coverage.

This transition supports strong access to care through NEtwork BLUE, Premier Select BlueChoice and BluePrint Health. Providers are encouraged to review each member’s ID card at every visit to confirm network selection and benefits. Participation details are available at NebraskaBlue.com/DoctorFinder.

Pharmacy drug coverage follow the Broad Network C formulary.

Members will have access to a variety of supportive programs designed to enhance care, including:

• Virta Health for diabetes management
• Progeny Health for maternity and NICU support
• Hinge Health for virtual physical therapy
• Nurse-supported programs that provide personalized guidance across a range of health needs

We appreciate your continued partnership in helping members achieve their best health and experience a smooth transition.

The Centers for Medicare and Medicaid Services conducts an annual Risk Adjustment Data Validation audit. The audit verifies diagnosis codes submitted for payment and the corresponding medical records.

Blue Cross and Blue Shield of Nebraska (BCBSNE) begins the process of retrieving medical records in June.

Under the terms of your contract with us, healthcare professionals and facilities agree to submit requested medical records to BCBSNE in a timely manner and at no cost to the patient or BCBSNE. Patients have already consented to the release of medical records to BCBSNE, and no additional authorization is required for this audit.

All information obtained as part of the review process is confidential.

The March 2026 Provider Bulletin marked the sunset of this publication. 

Blue Cross and Blue Shield of Nebraska (BCBSNE) continues to enhance provider communications by focusing updates through established, effective channels. Over time, provider communications have evolved with an emphasis on clarity, consistency and reduced duplication. Information previously shared in the Provider Bulletin is now delivered through channels providers already use for timely updates and operational guidance. 

Beginning in April 2026, the Provider Bulletins will be retired. BCBSNE will focus communications through the Provider UPDATE newsletter, a monthly publication, along with real-time communications available through our provider portal as well as Happening Now.   

Provider Update newsletter

The Provider UPDATE newsletter remains BCBSNE’s primary periodic publication. Published monthly, it includes policy updates, operational reminders, claims and billing guidance and other important information in a single digital format designed for easy reference. The UPDATE is an amendment to your provider agreement and contractual relationship.  

Providers are encouraged to: 

• Review the monthly Provider UPDATE newsletter for ongoing updates and reminders 
• Log in to NaviNet or check Happening Now regularly for announcements and time-sensitive information 
• Use NebraskaBlue.com as the primary reference for forms, policies and operational guidance 

BCBSNE remains committed to clear, consistent and meaningful communication with the provider community. This transition reflects our continued focus on delivering important information through tools that best support provider needs.

When services require prior authorization, a valid authorization must be obtained.

We are seeing an increase in appeals and reconsiderations for OptimizeRX claims denied due to no prior authorization when no authorization exists on file. Moving forward, these denials will be upheld when no authorization was obtained.

Appeals or reconsiderations submitted for OptimizeRX claims denied due to no authorization must include a valid authorization for review. If no authorization is provided, the denial will remain in place, even if additional documentation is submitted.

Please verify authorization requirements prior to services being rendered to help avoid denials and unnecessary appeals. We appreciate your partnership as we apply a consistent approach that supports accurate claims processing and a positive member experience.

When viewing a member with a dental‑only plan in NaviNet, the eligibility tab may display “no benefits” under dental. This is a known display limitation. The member’s dental coverage is active and can be confirmed by selecting the Schedule of Benefits (SOB). At this time, NaviNet reflects medical coverage only on the eligibility tab.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is pleased to announce a new partnership with ProgenyHealth to enhance maternity care and support healthier pregnancies beginning June 1, 2026.

ProgenyHealth is a national leader in maternity and neonatal care management, working collaboratively with health plans, providers and hospitals to support evidence‑based care throughout the perinatal journey. This partnership supports BCBSNE’s mission to make a lasting difference in the lives of members by improving health outcomes and care coordination for mothers and newborns.

Through this maternity program, eligible members gain access to specialized care management focused on healthy pregnancies, early identification of risk and coordinated support before and after delivery. ProgenyHealth’s experienced clinical team works alongside providers to promote best practices, reduce avoidable complications and support positive birth outcomes.

Member Identification and Eligibility in NaviNet

Providers should begin by accessing NaviNet to locate and review the subscriber or member information for active eligibility.

• Log in to NaviNet
• Search for the subscriber or member using available demographic information
• Navigate to the Benefits and Eligibility section

Identifying ProgenyHealth Enrollment

Once eligibility is confirmed, providers must determine whether the member is enrolled in the ProgenyHealth maternity program. Enrollment status is displayed in the Benefits and Eligibility section in NaviNet when a member is in session.

This step is critical, as notification and authorization workflows differ based on ProgenyHealth enrollment.

BCBSNE values its partnership with providers and looks forward to working together with ProgenyHealth to support healthier pregnancies and growing families across Nebraska.

Additional information about the ProgenyHealth maternity program is available at progenyhealth.com/portal/bcbsne-providers. Providers can access program resources, referral form and download a flyer to share with members.

Beginning June 1, 2026, ProgenyHealth will perform retrospective payment validation and assurance (PVA) on previously paid claims that are within a two-year lookback period, or a period in line with applicable BCBSNE provider contracts. 

• Retrospective PVA will apply only to claims associated with NICU admissions that occurred prior to the ProgenyHealth go-live date of May 4, 2026.

We are excited to share an upcoming enhancement that supports efficient care delivery and reduces administrative steps for providers caring for commercial members.

What providers can expect
Observation stays (OBS) will follow a streamlined process that allows providers to focus on patient care while supporting appropriate utilization management for inpatient services.

Under this update, observation services may be provided for up to 48 hours. When a member’s clinical condition supports an inpatient admission, authorization is requested at the point inpatient status is determined.

Inpatient precertification details
Precertification continues to apply to inpatient (IP) admissions for commercial members.

• Authorization is requested when inpatient status is initiated
• This applies regardless of when the admission decision occurs during the stay

Observation to inpatient transitions
For members who transition from observation to inpatient status:

• Same-day transitions: If inpatient admission occurs on the same date as observation, providers submit an authorization request for the inpatient stay
• All OBS to IP transitions: Authorization is requested when inpatient care begins

Important reminders

• This enhancement applies to commercial plans only
• Observation stays follow the updated process
• Inpatient admissions continue to follow precertification requirements

Additional guidance and details are available in Preauthorization and Precertification (GP-X-014).

We appreciate your continued partnership and look forward to supporting you with improvements that promote timely care and administrative simplicity.

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

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.

Find out more and how to ensure you are PAR with that network by visiting our Provider Academy - NaviNet FAQs under Benefits & Eligibility.

BCBSNE is pleased to announce a partnership with ProgenyHealth, a company specializing in Neonatal Care Management Services. This partnership enhances services for our members and supports our mission to make a lasting difference in our members’ lives by improving their health and well-being. 

Under the agreement beginning May 4, 2026, ProgenyHealth’s Neonatologists, Pediatricians and Neonatal Nurse Care Managers will work closely with BCBSNE members, as well as attending physicians and hospital staff, to promote healthy outcomes for premature and medically complex newborns. 

The Benefits of This Partnership to You 

• Support from a specialized team experienced in the complexity and stress of caring for infants in the NICU 
• A collaborative and proactive care management approach that supports timely and safe discharge to home 
• A partner committed to sharing best practices and working with NICUs nationwide to improve neonatal outcomes 

Families will have a dedicated case manager who provides education and support throughout the program, as well as access to an on-call clinical team available 24/7. For hospitals, ProgenyHealth will also serve as a liaison for BCBSNE by providing inpatient review services and assisting with discharge planning to ensure a smooth transition to the home setting. 

Member Identification and Eligibility Verification in NaviNet 

Providers should begin by accessing NaviNet to locate and review the member’s information. 

Access the Member in NaviNet

• Log in to NaviNet. 
• Search for the subscriber/member using available demographic information.  
  
  • A newborn most likely has not yet been added to the plan; however, using subscriber information allows providers to view how benefits apply under the policy. 
• Navigate to the Benefits and Eligibility section. 

Review Newborn Eligibility and 31-Day Coverage 
If the newborn is not yet added to the plan, providers must determine whether the newborn is eligible for free automatic 31‑day coverage, which allows the newborn to be automatically loaded to the plan.

• This information is available on the subscriber/member’s Benefits and Eligibility page in NaviNet. 
• The page will indicate:  
  
  • Whether the newborn qualifies for automatic 31‑day coverage, or 
  • Whether the newborn must be formally added to the plan by the employer group. 
• This eligibility determination should be confirmed before proceeding with notification or authorization submissions. 

Identifying ProgenyHealth Program Enrollment 

Once eligibility is confirmed, providers must determine whether the member is enrolled in the ProgenyHealth program. 

• ProgenyHealth enrollment status is displayed in the Benefits and Eligibility section in NaviNet when a member is in session. 
• Review this section to confirm whether ProgenyHealth care management applies.  
  
  • This step is critical, as notification and authorization workflows differ based on ProgenyHealth enrollment.

Notification and Authorization Submission Guidance 

If the Member Is Enrolled in the ProgenyHealth Program 

Effective May 4, 2026, providers must notify ProgenyHealth directly of: 

• NICU admissions, or 
• Admissions to special care nurseries related to NICU-level services. 

Notifications should be submitted via fax at 800‑540‑9492. ProgenyHealth clinical staff will contact your designated hospital staff to provide utilization management and discharge planning support throughout the inpatient stay. 

Important ProgenyHealth Guidance

• If an infant is admitted to the NICU at birth and managed by ProgenyHealth, any subsequent NICU-related admissions during the first year of life should continue to be directed to ProgenyHealth. 

If the Member Is Not Enrolled in ProgenyHealth 

• Follow standard BCBSNE notification and utilization management processes. 
• If the member cannot be located in NaviNet after eligibility review, submit a Universal Prior Authorization (PA) Request Form. 

Important: 
If a Universal PA Request Form is submitted for a member who is enrolled in the ProgenyHealth program, the request will not continue through BCBSNE and the provider will be redirected to submit the notification directly to ProgenyHealth.

Special Guidance for Children Under One Year of Age

• A child under one (1) year of age who was not admitted to the NICU at birth, regardless of whether ProgenyHealth applies, will be managed by BCBSNE using standard processes. 

If you wish to learn more about ProgenyHealth’s programs and services, visit ProgenyHealth. Thank you for your partnership in caring for BCBSNE members. 

Update – April 1, 2026:
Beginning June 1, 2026, ProgenyHealth will perform retrospective payment validation and assurance (PVA) on previously paid claims that are within a two-year lookback period, or a period in line with applicable BCBSNE provider contracts.

• Retrospective PVA applies only to claims for NICU admissions occurring prior to the ProgenyHealth go-live date of May 4, 2026.

Feb. 2, 2026
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.

Continue to watch Happening Now for additional details as we get closer to the launch date.