Optional H2 Subhead
Provider Update September 2026
Welcome to your Provider Update Newsletter, bringing together important updates for our medical, dental and Medicare Advantage products in one convenient publication.
What's inside
| General Information |
Correct submission of Appeals and Reconsiderations |
| Medical: Commercial and FEP |
|
| Claims |
Timely Filing reminder: Returned and rejected Claims are not eligible for override review New CPT codes for maternity care services effective Jan. 1, 2027 |
| Clinical, Authorization and Appeals |
Prior authorization required for hip, knee and shoulder surgeries effective Nov. 1, 2026 |
| Payment Integrity |
ED coding review and appeal process update |
| Dental |
Dental Fee Schedule clarification |
| Medicare Advantage (MA)/P3 |
|
| Claims |
Medicare Advantage claims processing update MA Claim Appeal update for services without Prior Authorization |
| Clinical, Authorization and Appeals |
Medicare Advantage Prior Authorization Appeals & Grievance process update |
| Security Corner |
Brand impersonation |
General information
Important Update: Correct submission of Appeals and Reconsiderations
As announced on Happening Now on July 29, providers must submit appeals, reconsiderations and other claim-related requests using the appropriate submission type and channel effective Sept. 1, 2026.
To help ensure timely review and processing, requests submitted under the incorrect category may be returned with instructions for resubmission. Examples include:
- Appeals submitted as claim reconsiderations
- Claim reconsiderations submitted as appeals
- Medical records submitted through an incorrect submission pathway when alternate instructions have been provided
Providers should carefully review the submission options available through NaviNet® and follow any instructions included in correspondence from Blue Cross and Blue Shield of Nebraska (BCBSNE) regarding how and where supporting documentation should be submitted.
Submitting requests through the correct pathway helps:
- Reduce processing delays
- Improve routing accuracy
- Ensure timely handling of appeals and reconsiderations
- Minimize administrative rework for both providers and BCBSNE
If a request is returned because it was submitted under the wrong request type, the return notification will include instructions on how to submit the request correctly.
We encourage providers to review their internal processes and educate staff responsible for submitting appeals, reconsiderations and supporting documentation prior to the effective date.
Thank you for your partnership and commitment to efficient claims and appeals processing.
Medical: Commercial and FEP
Claims
Timely Filing reminder: Returned and rejected claims are not eligible for override review
BCBSNE continues to receive Timely Filing Override Requests for claims that were previously returned or rejected for correction. These requests do not meet timely filing exception criteria and are generally upheld.
Providers are responsible for monitoring claim activity in NaviNet, including return letters, rejection notices and clearinghouse reports. When a claim is returned or rejected due to missing, incomplete or incorrect information, the claim must be corrected and submitted as a new claim within the applicable timely filing limit.
Please remember:
- Returned or rejected claims are not considered proof of timely filing
- Provider processing delays do not qualify for a timely filing exception
- Submitting a Timely Filing Override Request for a returned or rejected claim will not result in an overturn when the original claim required correction
Timely Filing Override Requests should be reserved for situations that meet the exception criteria outlined in Policy GP-X-046. Proactively reviewing and correcting returned or rejected claims before timely filing expires helps reduce administrative burden, improve processing efficiency and avoid unnecessary denials.
New CPT codes for maternity care services effective Jan. 1, 2027
Effective Jan. 1, 2027, the American Medical Association will update Current Procedural Terminology (CPT®) codes for maternity care services. This change replaces global obstetric codes with a new code set that reflects how care is delivered today.
The updated codes support more accurate reporting across prenatal, labor, delivery and postpartum services, allowing care to be represented based on when and where it occurs.
The new code set provides:
- Flexible care transitions, including transfers at any stage of care
- Accurate reporting of extended labor, including services across multiple days
- Enhanced data insights to support maternal health outcomes
Please watch Provider Updates for additional information and guidance as implementation approaches.
Clinical, Authorization and Appeals
Prior authorization required for hip, knee and shoulder surgeries effective Nov. 1, 2026
On Nov. 1, 2026, prior authorization will be required for select hip, knee and shoulder surgical procedures for all employer groups. Evolent™ will perform prior authorization reviews for these services. A list of affected procedures is provided below.
The following procedures require prior authorization under Medical Policy III.277
| Procedure | CPT code(s) |
| Revision/Conversion Hip Arthroplasty |
27132, 27134, 27137, 27138 |
| Total Hip Arthroplasty/Resurfacing |
27130, S2118 |
| Femoroacetabular Impingement (FAI) Hip Surgery |
29914, 29915, 29916 |
| Hip Surgery – Other |
29860, 29861, 29862, 29863 |
| Revision Knee Arthroplasty |
27486, 27487 |
| Total Knee Arthroplasty (TKA) |
27447 |
| Partial-Unicompartmental Knee Arthroplasty (UKA) |
27446, 27438 |
| Knee Manipulation under Anesthesia (MUA) |
27570, 29884 |
| Knee Ligament Reconstruction/Repair |
27405, 27407, 27409, 27427, 27428, 27429, 29888, 29889 |
| Knee Meniscectomy/Meniscal Repair/Meniscal Transplant |
27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883 Knee Surgery – Other 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866, 29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29885, 29886, 29887, G0289 |
| Revision Shoulder Arthroplasty |
23473, 23474 |
| Total/Reverse Shoulder Arthroplasty or Resurfacing |
23472 |
| Partial Shoulder Arthroplasty/Hemiarthroplasty |
23470 |
| Frozen Shoulder Repair/Adhesive Capsulitis |
29825 |
| Shoulder Labral Repair |
23450, 23455, 23460, 23462, 23465, 23466, 29806, 29807 |
| Shoulder Rotator Cuff Repair |
23410, 23412, 23420, 29827 |
| Shoulder Surgery - Other |
23120, 23125, 23130, 23405, 23415, 23430, 23700, 29805, 29819, 29820, 29821, 29822, 29823, 29824, 29825, +29826, 29828 |
Submit prior authorization requests
- Call Evolent at 1-866-972-9642 between 7 a.m. and 7 p.m. CST (8 a.m. to 8 p.m. EST)
- Submit requests online through RadMD
Thank you for your partnership in providing quality care to our members.
Payment Integrity
ED coding review and appeal process update
As a reminder, BCBSNE continues to partner with Conduent to conduct coding reviews of Emergency Department (ED) claims to support accurate and consistent reimbursement, as communicated on Happening Now and NaviNet on July 21, 2026.
Providers who wish to submit a second-level appeal related to an ED coding review should send their appeal and supporting documentation to PaymentIntegrityProviderReviews@NebraskaBlue.com.
To help reduce administrative burden, providers may submit multiple ED coding review appeals as a single bulk submission rather than sending appeals individually. We encourage providers to use the bulk appeal process whenever possible.
Dental
Dental Fee Schedule clarification
Providers may notice that certain D codes appear on both the Medical Fee Schedule and the Dental Fee Schedule. In some cases, the reimbursement amounts displayed on the MD Fee Schedule are lower than the amounts shown on the Dental Fee Schedule.
For example:
- D7240 – Removal of impacted tooth
- Dental Fee Schedule: $487.01
- MD Fee Schedule: $280.04
Please note that claims submitted with applicable D codes are reimbursed according to the Dental Fee Schedule rates, not the rates displayed on the Medical Fee Schedule.
D codes have appeared on the Medical Fee Schedule for several years, including prior fee schedules dating back to 2024. The presence of these codes on the Medical Fee Schedule does not change reimbursement under the Dental Fee Schedule.
Medicare Advantage (MA)/P3
Claims
Medicare Advantage claims processing update
What providers need to know:
- No changes are required to current claim submission practices
- This update does not change provider contract terms or Medicare Advantage reimbursement policies
- Claims will reimburse based on the applicable Medicare Advantage allowable amount or the billed charge, whichever is less
- In certain situations, claims billed below the applicable allowable amount, reimbursement will continue to be limited to the billed charge amount
- BCBSNE will reprocess and adjust impacted claims consistent with contractual recoupment provisions
MA Claim Appeal update for services without Prior Authorization
What is changing?
Beginning Oct. 17, 2026, providers will no longer be able to submit a claim appeal or request a retrospective medical necessity review for services that required prior authorization but were performed without obtaining the required authorization before services were rendered.
What does this mean for providers?
Claims denied due to a missing required prior authorization will not be eligible for appeal or further medical necessity review. Additionally, services rendered following a prior authorization denial are not eligible for reconsideration or review.
Provider Action Required
To avoid claim denials that cannot be appealed:
- Verify prior authorization requirements before services are rendered.
- Submit authorization requests and obtain approval prior to providing services that require authorization.
- Review current prior authorization requirements and applicable Medicare Advantage resources.
- Ensure authorization decisions are received before scheduling or performing services when authorization is required.
- Policy and Procedure Update
Clinical, Authorization and Appeals
Medicare Advantage Prior Authorization Appeals & Grievance process update
What this means for providers:
- No action is required at this time.
- Providers should continue to submit prior authorization requests and related documentation through existing processes.
- No significant changes to provider workflows are anticipated as part of this transition.
- The transition is intended to support a seamless experience for providers and members while maintaining timely review and resolution of appeals and grievances.
Security Corner
Brand Impersonation
Healthcare organizations are some of the world’s most trusted brands, making them some of the most popular for cybercriminals to impersonate.
If you hear from a patient or colleague that they saw your brand being used by someone other than your organization, notify your organization’s legal or marketing team. Don’t let decades of building trust with patients and the community be undermined by one cybercriminal impersonating your brand.
Stay informed with BCBSNE provider communications
Log in to NaviNet Plan Central and sign up for BCBSNE provider emails to receive notifications when new Provider Updates are available. Provider Updates are an extension of your provider contract and may include important operational, policy and administrative information. Be sure your contract and contact information are current so you receive timely updates and communications from BCBSNE.