Happening Now

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.

Effective Nov. 17, 2025, Commercial and Federal Employee Program preauthorization and pre-certification requests must be submitted digitally through NaviNet^® or the universal preauthorization request form for out-of-network and out-of-state providers. Faxed requests will not be accepted or processed.

For commercial preauthorization requests submitted through the Universal PA Request form, all medical records and required documentation must be uploaded online at the time of submission, including medical records, clinical notes and supporting information.

Submitting all materials together helps support faster review and reduces administrative delays. If a request was originally submitted through NaviNet, any additional documentation must be uploaded directly in NaviNet, not through the Universal PA Request form.

Fax numbers should not be used for preauthorization or pre-certification submissions.

Visit Provider Academy for resources and FAQs.

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. 

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) will begin the process of retrieving medical records in June.

Under the terms of your contract with us, health care 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.

On April 1, 2026, the Coordination of Benefits (COB) forms were removed from our website.

Members must update their COB information directly with their health plan. BCBSNE members can complete COB updates through MyBlue or by calling Customer Service.

Paper submissions cannot be processed and will be securely disposed of. Please encourage your patients to submit COB information electronically.

What We’re Doing

• Expanded staffing and targeted support: We have temporarily increased clinical and administrative staffing across our authorization teams to help reduce the entire backlog of faxed prior authorization requests. Efforts are underway to expedite processing and improve turnaround times. We estimate noticeable progress in the next 6 weeks as the current volumes include approximately 20% duplicate requests and other non-authorization notifications. If asked, please tell your providers to avoid submitting duplicate prior authorization requests, as this will help us get through our inventory as more quickly.
• System enhancements: Our technical teams continue to stabilize the upgraded platform to reduce processing delays and prevent further additional disruptions.
• Workflow and process improvements: We are completing a comprehensive review of authorization and claims workflows. This work will result in phased improvements over the next 30–60 days to address identified defects, with longer term system and process enhancements targeted for completion later this year. 
• Important note: Emergent or urgent services that, if delayed, would cause immediate harm to the patient do not require prior authorization. Providers should proceed with medically necessary emergency care in accordance with policy.

As a reminder, the Consolidated Appropriations Act (CAA) requires certain provider directory information to be verified every 90 days. BCBSNE participating providers must verify and attest to the accuracy of their information in the CAQH Provider Data Portal.

Even if your information has not changed, you are still required to attest every 90 days.

Failure to complete this attestation may result in removal from BCBSNE’s provider directory. Under the CAA, BCBSNE is required to remove providers whose data cannot be verified.

To avoid disruption in your directory listing and ensure patients can find your practice, please log in to CAQH and complete your attestation.

For questions or support, visit the CAQH Provider Data Portal or contact your Provider Partnerships Advocate.

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.

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.