Happening Now

To help ensure timely resolution of claim-related inquiries and reduce unnecessary submissions, we encourage providers and billing staff to review the resources available through the Provider Academy and our Policies and Procedures before contacting Customer Service or submitting a claim investigation request.

Claim status inquiries

Customer Service representatives will direct claim status inquiries to NaviNet. Providers should use NaviNet as the primary source for claim status information before contacting Customer Service.

Using NaviNet allows providers to access real-time claim information quickly and efficiently, often eliminating the need for additional follow-up.

Claim investigations

Before submitting a claim investigation request, please review the applicable guidance, training materials and policies to verify that all available claim information has been reviewed and that the inquiry meets the criteria for investigation.

Reconsideration requests

We also ask providers to carefully review the Reconsideration Requests - GP-X-073 policy before submitting a reconsideration request. Understanding the eligibility requirements and appropriate submission criteria can help prevent unnecessary or duplicate requests and help ensure requests are submitted through the correct process the first time.

Reviewing these resources before submitting an inquiry helps streamline processing, reduce delays and allow our teams to focus on resolving issues that require additional review.

Thank you for your partnership in caring for BCBSNE members.

Effective Jan. 1, 2027, BCBSNE will implement new maternity codes associated with industry-wide maternity coding changes.

Maternity services will be reimbursed separately by phase of care, including antepartum care, labor management, delivery and postpartum services.

Updated fee schedules will be made available when finalized. The Obstetrical/Maternity Services, RP-PI-003 policy will also be updated with reimbursement guidelines.

Watch for the updated fee schedules and policy for complete reimbursement detail

The previously announced Nov. 1, 2026, implementation date for the new Evolent™ prior authorization requirement for select joint surgery procedures has been postponed.

A new effective date has not yet been determined. Providers should continue to follow current BCBSNE prior authorization requirements until further notice.

BCBSNE will post an update on Happening Now once the new implementation date is finalized.

^{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}

Beginning Jan. 1, 2027, an industry-wide change will affect how pregnancy-related health care services are billed. The American Medical Association (AMA) is implementing a significant update to maternity coding. As part of this change, the traditional global maternity billing package will be eliminated, and maternity care services will instead be billed separately throughout the pregnancy journey.

What providers need to know:

• Pregnancy care will be billed across multiple phases, including prenatal care, labor management, delivery and postpartum care.
• Providers may submit multiple claims throughout a pregnancy rather than a single bundled maternity claim.
• The new coding and billing standards take effect Jan. 1, 2027.

BCBSNE is evaluating the operational and benefit impacts of these changes and preparing for the transition to the new billing requirements.

Please share information about this upcoming change with your patients, as appropriate. BCBSNE will share additional information, including provider billing guidance and any necessary next steps, as details become available.

The preferred way to submit a formulary exception request is electronically through CoverMyMeds or the online preauthorization form.

If submitting a formulary exception request by fax, please select the Formulary Exception Form based on the member’s benefit plan:

• Qualified Health Plans: Use the Formulary Exception Form (Qualified Health Plans Only) for Affordable Care Act plans
• All other benefit plans: Use the Formulary Exception Form

Please note: To help avoid delays, make sure the Formulary Exception Form is complete before submitting it. Incomplete forms will be returned.

Preauthorization requests must be submitted online through CoverMyMeds or the online preauthorization form.

Preauthorization requests faxed using a Formulary Exception Form will be returned.

Beginning Jan. 1, 2027, Blue Cross and Blue Shield of Nebraska will offer Enhanced Dental Benefits for eligible dental plan members. Members with certain medical conditions may qualify for additional preventive dental services, including extra cleanings and fluoride applications.

Eligible conditions include:

• Cancer-related chemotherapy and/or radiation
• Diabetes
• High-risk cardiac conditions
• Kidney failure or dialysis
• Periodontal (gum) disease
• Pregnancy
• Suppressed immune systems

Please verify members' eligibility and plan benefits before providing services, as Enhanced Dental Benefits vary by health condition and plan design.

For complete details about Enhanced Dental Benefits, including eligible conditions and available services, see the October 2026 issue of Provider Update.

Effective Jan. 1, 2027, Blue Cross and Blue Shield of Nebraska (BCBSNE) will implement federal interoperability and prior authorization transparency requirements under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). BCBSNE will publish annual prior authorization metrics, maintain information regarding services requiring prior authorization and make available educational resources related to health information exchange initiatives. For more information, visit the CMS Interoperability and Prior Authorization Final Rule webpage. 

At this time, no action is required from providers. Additional details will be shared in upcoming provider communications prior to the Jan. 1, 2027, effective date.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is preparing to transition from NaviNet^® to the Availity Provider Portal in the second quarter of 2027.

As part of this transition, providers will gain access to enhanced self-service tools designed to streamline workflows, improve access to information and create a more connected provider experience.

What's new with Availity?

Providers can look forward to several enhancements, including:

• Submit claims electronically and attach supporting documentation (PDFs) through the portal
  
• Enhanced claim status information, including additional details related to denials
• Expanded correspondence access, with more letters available and improved search capabilities
• Expanded secure messaging functionality for provider inquiries and communications
• Direct links to authorization resources and portals
  
• Access to a multi-payer platform, allowing providers to work with multiple health plans through a single portal. Registered users will simply add Blue Cross and Blue Shield of Nebraska to their existing Availity account.

What will stay the same?

While the access point is changing from NaviNet to Availity, providers will continue to have access to many of the same resources they use today, including:

• Eligibility and benefits information
• Claim status inquiries
• Authorization resources
• Provider inquiries and communications
• Provider documents and resources

What to expect

The transition is planned for the second quarter of 2027. Additional details, including registration information, training opportunities, timelines and support resources, will be shared in future provider communications as the launch date approaches.

Stay tuned to Happening Now, the Provider Update newsletter and other BCBSNE provider communications for the latest information.

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 DataSpring, powered by CAQH and complete your attestation.

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

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

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.

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.