Provider Update April 2026

Medicare Advantage

Medicare Advantage (MA) prior authorization update with P3 Health

BCBSNE continues preparations for upcoming MA operational enhancements in partnership with P3 Health, with phased implementation beginning May 1, 2026. These changes are intended to enhance care coordination, improve administrative efficiency and support providers while maintaining continuity for members.

The information below reflects the most recent updates related to prior authorization submission and portal access.
 
Prior Authorization Submission and Portal Access (Effective May 1, 2026)

• MA prior authorization requests will be submitted through the P3 Provider Portal.
• Providers are expected to access the P3 Provider Portal through NaviNet using Single Sign‑On (SSO) once live.
• Authorization decisions will be communicated via fax.
  Authorization submitted after May 1, 2026, status can be viewed within the P3 Provider Portal
• Details for authorization submitted prior to May 1, 2026, will continue to be available in NaviNet
• Existing preauthorization phone and fax numbers will remain unchanged unless otherwise communicated.

Authorization Turnaround Time (TAT)

• Authorization TAT begins only after:
  
  • Portal access has been successfully established, and
  • A complete authorization request has been submitted.
• Standard MA authorization TATs include:
  
  • Urgent requests: 72 hours
  • General requests: 7 calendar days 

FYI: Automated authorization approvals
As part of the transition to the P3 partnership, providers may notice a temporary change in automated authorization approvals:

• Beginning May 1, 2026, MA authorization requests will continue to be reviewed appropriately; however, real‑time automated approvals may be limited during May as processes transition.
• During this period, authorization requests may require manual review, which could affect immediate decisioning.
• Beginning June 1, 2026, P3 will introduce enhanced automation to support on‑the‑spot authorization approvals, where applicable.

No action is required from providers at this time. This temporary change is part of the planned transition, and normal turnaround times will continue to apply.
 
Reminder: Use of third‑party vendors
Providers using third‑party vendors, including offshore support teams, should be aware that access to the P3 Provider Portal will follow the same access requirements currently in place for NaviNet and other preauthorization portals. Vendors without appropriate U.S.‑based access may not be able to log in to the portal.

Providers are encouraged to review the Preauthorization FAQ for full details and guidance on third‑party and offshore vendor access considerations.
 
Updates will continue to be posted on NebraskaBlue – MA Happening Now, as needed, and will focus on new or updated information only. Prior updates will remain available below in a collapsed format for reference. Providers are encouraged to check back regularly as additional details are shared ahead of the 2026 implementation.

Medicare Advantage policy update: Chiropractic care, effective July 1, 2026

As we announced on Happening Now last month, we’ve updated our Medicare Advantage Chiropractic Care policy to clarify how routine services are defined. These changes support accurate coding and smooth claims processing. Please see Policy MA‑X‑082 for complete details.

Medicare covers spinal manipulation when it is medically necessary and billed with the correct CPT codes and the AT modifier, which should not be used for routine or maintenance care.

Routine services, including non‑Medicare spinal or extraspinal manipulation, therapeutic procedures, radiology and office visits, are not covered by Original Medicare.

BCBSNE Medicare Advantage plans include enhanced routine chiropractic benefits. Members have a $20 copay per routine visit and receive one set of diagnostic X‑rays each year at no cost when completed by a chiropractor.

Accurate documentation, medical necessity and correct coding remain required. Claims with incorrect modifiers or unsupported diagnoses may be denied.

Medical: Commercial and FEP

Provider notice: Update to reconsideration process effective April 2026

As we shared on Happening Now in February, 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 process 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.

Update: Enhanced NICU support with ProgenyHealth coming May 2026

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.

Retrospective payment validation and assurance (PVA)
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.

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

Quality and Risk

Ensuring accuracy: BCBSNE's upcoming risk adjustment data validation audit

CMS conducts an annual Risk Adjustment Data Validation (RADV) audit. The RADV audit verifies diagnosis codes submitted for payment, along with the corresponding medical records. BCBSNE will begin the process to retrieve medical records in March/April. Under the terms of your contract with us, health care professionals and facilities agree to submit medical records requested by BCBSNE in a timely manner at no cost to the patient or BCBSNE. Patients have consented to release medical records to us. An additional release is not required for this audit. All information resulting from the review is confidential.

Chronic Kidney Disease (CKD): Accurate documentation for risk adjustment and patient care

Chronic Kidney Disease (CKD) is a chronic condition that significantly influences patient outcomes and health risk. As CMS continues to emphasize specificity under the current risk adjustment model, precise documentation of CKD; including stage and associated conditions such as diabetes and hypertension is essential to accurately reflect disease burden and support appropriate reimbursement.

1. Document the stage of CKD
   CKD must always be documented with its specific stage, as staging directly impacts HCC capture   
   and clinical management.
   • Stage 1–5 
   • End-Stage Renal Disease (ESRD) 

 Examples:

• “CKD stage 3b” 
• “CKD stage 5, not on dialysis” 
• “ESRD on hemodialysis” 

Missed opportunity:
Documenting “CKD” without a stage does not support accurate coding.

2. Capture linkage to diabetes and hypertension
   When clinically appropriate, CKD should be linked to its underlying cause, most commonly diabetes and/or hypertension. This provides a more complete clinical picture and ensures accurate management of the patient.
    
   Examples:

• “Type 2 diabetes with diabetic CKD stage 3” 
• “Hypertensive CKD stage 4” 
• “CKD stage 3 due to long-standing hypertension and diabetes” 

Linking conditions demonstrates disease progression and complexity, which is critical for both care planning and coding accuracy.
 
Missed opportunity:
Documenting diabetes, hypertension, and CKD separately without linkage results in loss of clinical context.

3. Document CKD at every visit (when applicable)
   CKD is a chronic, lifelong condition that should be assessed and documented regularly, even when
   stable.
    
   Include:

• Current stage 
• Stability or progression 
• Treatment plan (e.g., ACE inhibitor use, nephrology follow-up, dialysis status) 

Example:
“CKD stage 3b, stable, continuing ACE inhibitor, followed by nephrology.” 

4. Ensure documentation reflects active management (MEAT) or DSP
   To support coding and risk adjustment, documentation should reflect:

• Monitor: Labs (e.g., eGFR, creatinine) 
• Evaluate: Disease progression or stability 
• Assess/Address: Clinical status and comorbidities 
• Treat: Medications, referrals, dialysis planning 

OR

• Diagnosis
• Status 
• Plan

Why it matters
Incomplete or nonspecific CKD documentation can result in:

• Missed HCC capture 
• Underrepresentation of patient complexity 
• Gaps in care coordination 
• Increased audit risk 

Accurate documentation ensures that patients receive appropriate care management while providers are reimbursed appropriately for the complexity of care delivered.

Key takeaway
CKD should never be documented generically. Always include the stage, linkage to underlying conditions and evidence of ongoing management. Doing so strengthens both coding accuracy and patient care outcomes.

Chronic conditions that drive risk adjustment accuracy

As Medicare Advantage continues to evolve under the 2024 CMS-HCC (V28) model, accurate and specific documentation of chronic conditions is more important than ever. This updated model emphasizes fewer, more clinically meaningful HCCs, making it essential to fully capture the severity, complexity and ongoing management of chronic diseases at every encounter.
 
Chronic conditions such as diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) remain key drivers of risk scores and present an important opportunity for improved accuracy through more complete and specific supporting documentation. These conditions should be assessed, addressed and documented annually—and ideally at every visit when applicable—to ensure accurate representation of patient complexity and appropriate reimbursement.

High-impact chronic conditions and documentation tips

Diabetes Mellitus

• Always document type (Type 1, Type 2, secondary) and complications (e.g., nephropathy, neuropathy, retinopathy). 
• Link complications clearly, if present: “Type 2 diabetes with diabetic CKD stage 3.” 
• Avoid unspecified diabetes codes when more detail documentation is available. 

Missed opportunity:
Documenting only “diabetes” without complications when “diabetes with polyneuropathy” is present. 

Congestive heart failure (CHF)

• Specify type and acuity: 
  
  • Systolic vs. diastolic vs. combined 
  • Acute, chronic, or acute on chronic 
• Include clinical status and treatment plan. 

Missed opportunity:
Using “CHF” alone instead of “chronic systolic heart failure.”

Chronic obstructive pulmonary disease (COPD)

• Identify specific conditions such as: 
  
  • Chronic bronchitis 
  • Emphysema (takes coding precedence when applicable) 
• Document exacerbations and treatment (e.g., steroids, oxygen use). 

Missed opportunity:
Documenting “COPD” without noting exacerbation or subtype.

Chronic kidney disease (CKD)

• Always include stage (1–5, ESRD). 
• Link to underlying conditions when applicable: 
  
  • “CKD stage 3 due to diabetes” 
• Ensure consistency with labs and treatment plan. 

Missed opportunity:
Documenting “CKD” without stage.

Key documentation reminders

• Be Specific: Capture the highest level of detail supported by the clinical picture. 
• Use MEAT Criteria: 
  
  • Monitor, Evaluate, Assess/Address, Treat
  • Each chronic condition must show ongoing management. 

OR

• Use DSP criteria:
  
  • Diagnosis, Status, Plan
• Document annually: Chronic conditions must be re-documented each calendar year to be captured. 
• Link conditions when appropriate: Show relationships (e.g., diabetes with CKD, hypertension with heart disease). 
• Avoid copy-forward without updates: Ensure documentation reflects the current status of the condition. 

Why it matters
Incomplete or nonspecific documentation can lead to:

• Missed conditions while managing the patient 
• Inaccurate representation of patient complexity 
• Increased audit risk 

Accurate documentation ensures that patients receive appropriate care planning and that providers are appropriately reimbursed for the complexity of care delivered.

Bottom line
Chronic conditions don’t “fall off”—but they must be actively documented. By focusing on specificity, linkage and ongoing management, providers can significantly improve both risk adjustment accuracy and patient care outcomes.

Dental

Oral appliances for sleep apnea treatment

As posted to Happening Now in February, the BCBSNE medical policy for treating obstructive sleep apnea (OSA) includes oral appliances as one of several covered treatment options. Preauthorization is required for sleep apnea treatment for BCBSNE members; without it, claims will be denied as provider liability.

Because dentists are best qualified to evaluate patient suitability for an oral appliance and perform dental impressions, BCBSNE provides specific billing and coding guidelines to support accurate submission.

Key points for providers

• Preauthorization is required for sleep apnea treatment; claims without preauthorization 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.