Medicare Advantage

Effective May 1, 2026, BCBSNE will implement several MA prior authorization process changes as part of our partnership with P3 Health. These updates affect how certain authorizations are submitted, reviewed and tracked, and are intended to support consistent operations and continuity of care during the transition.

The information below summarizes what providers can expect beginning May 1, 2026.

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 using InterQual medical necessity criteria; however, real‑time automated approvals may be limited during May.
• Some requests may require manual clinical review, which could affect immediate decisioning.
• Requests submitted for services that do not require prior authorization and are covered benefits under the member’s plan will continue to receive automated approval and will not be denied or rejected.
• To help reduce turnaround time and avoid unnecessary submissions, providers are encouraged to confirm prior authorization requirements by reviewing MedPolicy Blue  before submitting a request.

Standard authorization turnaround times will continue to apply.

Transition of MSK, IPM, and Medical Pharmacy Prior Authorization
Effective May 1, 2026:

• Prior authorization requests for Musculoskeletal (MSK) and Interventional Pain Management (IPM) services previously managed through Evolent will transition to P3 Health and be submitted through the P3 Provider Portal.
• Medical Pharmacy prior authorization requests for Medicare Advantage Part B medications previously managed through the OptimizeRx program via the GatewayPA portal will also transition to P3 Health.

These services will follow the same submission process and medical criteria updates applicable to all MA prior authorizations under the P3 partnership.

Checking MA Prior Authorization Status
Checking prior authorization status online is the fastest and preferred method. Where providers check status depends on when the authorization request was submitted.

Online Status Check (Preferred):

• Authorizations submitted prior to May 1, 2026
  Continue to check status in the same system where the request was originally submitted, such as NaviNet or the applicable authorization portal.
• Authorizations submitted on or after May 1, 2026
  Check status in the P3 Provider Portal, which will be accessible through NaviNet once live.

Phone Support:

• Effective May 1, 2026, automated authorization status will no longer be available through the IVR.
• Authorization status can be accessed via the P3 Provider Portal. Once a decision is made a letter will be faxed.

Online access remains the most efficient way to obtain real‑time authorization status.

Prior Authorization Decision Letters & Appeals
If a MA prior authorization request is denied, providers will receive a written decision letter outlining the determination.

If an appeal is needed, it must be submitted using the fax number listed on the decision letter, following the instructions provided.

• All MA prior authorization, including IP, requests must be submitted through the P3 Provider Portal 
• Access will be via NaviNet (clicking in the Medicare Advantage Prior Authorizations link)
• Authorization decisions will be communicated via fax
• Authorizations submitted after May 1:
  
  • Status viewable in the P3 Provider Portal
• Authorizations submitted prior to May 1:
  
  • Details remain available in NaviNet
  • Exception: Continued stays or IP procedures beyond midnight on April 30 will need to be managed by P3
• Existing phone and fax numbers remain unchanged unless otherwise communicated 

For Out of State (OOS) or NonPar Providers

• May 1: OOS and NonPar providers need to submit MA preauths via phone/fax with the transition to P3.
  
  • PHONE: MA UM Auth Intake Line – 877-399-1671
  • FAX: MA UM Pre Service Auths – 866-422-5120
  • FAX: MA UM Inpatient and LLOC – 866-659-0165
  • Umanagement@p3hp.org

Additional updates will continue to be posted on continue to be posted here, 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 implementation approaches.

BCBSNE is providing guidance to support accurate and timely submission of MA Skilled Nursing Facility (SNF) concurrent reviews through the P3 portal. Following the process below will help reduce delays, prevent duplicate cases, and ensure efficient review of continued stay requests.

When submitting a concurrent review, providers should select the appropriate authorization settings. The correct authorization type is Concurrent Review, and the priority should remain Standard. Selecting the correct options ensures the request is routed appropriately for review.

Clinical documentation plays a critical role in the review process. Providers should upload clinical documentation directly to the authorization at the time of the initial request within the portal. After submission, facilities are encouraged to proactively provide clinical updates approximately every three (3) days by attaching supporting medical records to the existing authorization.

To avoid processing delays and duplication:

• Do not submit a new authorization request to request additional days
• Do not submit multiple updates covering the same time period, as this may create duplicate cases or overload processing queues

Once a request is submitted, timing for case visibility will vary based on the submission method. Requests submitted through the portal will appear once processed. If documentation is submitted via fax, providers should allow at least 24 hours for the P3 Care Navigation team to build the case before it becomes fully visible in the Auth Center.

During the concurrent review process, facilities will be notified if a patient no longer appears to meet medical necessity criteria. In these situations, the P3 Care Navigation Team will outreach to the facility and begin the Notice of Medicare Non-Coverage (NOMNC) process, as appropriate.

Finally, it is important to correctly assign provider roles within the authorization to ensure proper routing and review. When completing the request:

• The requesting provider should be the provider at the submitting facility
• The servicing provider and servicing facility should reflect the SNF receiving the patient

Adhering to this guidance will support clear communication, minimize administrative burden, and help ensure timely determinations for SNF concurrent reviews.

Providers may receive preauthorization decision faxes from P3 Health even if they did not submit the request. 

Primary Care Providers (PCPs) will receive the authorization decision as part of their role as the member’s PCP, regardless of which provider initiated the preauthorization.

No action is required if you are not the requesting provider. These communications are being shared for care coordination and awareness.

Blue Cross and Blue Shield of Nebraska (BCBSNE) would like to inform providers that Stellus Rx will be conducting outreach on behalf of P3 Health Partners to support Medicare Advantage (MA) Part D gap closure efforts.

What to Expect

Stellus Rx will act as an extension of P3 Health Partners to help address medication adherence opportunities and support patients throughout their care journey. Outreach may include:

• Contacting patients with due or past-due prescription refills
• Reaching out to patients with identified medication gaps
• Answering medication-related questions or concerns
• Providing access to a pharmacist via phone or text (when referred by a provider)
• Notifying provider offices of patient concerns or potential care changes, as appropriate
• Stellus may also conduct outreach on other Part D gaps as appropriate

What This Means for Providers

• Patients may be contacted directly by Stellus Rx pharmacists or support team members
• Stellus Rx may coordinate with provider offices if follow-up or clinical input is needed
• This outreach is intended to improve medication adherence and overall patient outcomes

BCBSNE appreciates your partnership in supporting coordinated care and improving medication adherence for Medicare Advantage members.

BCBSNE has officially transitioned MA utilization management criteria from InterQual to MCG (Milliman Care Guidelines), effective June 1, 2026.

What’s Changed

• MCG guidelines are now in use for all MA utilization management reviews
• InterQual is no longer applied for MA medical necessity determinations

Accessing MCG in NaviNet

• Navigate to the MA Prior Authorization Workflow in NaviNet
• Select the MCG Health Client Log In
• Additional access details are available under the Resources section in NaviNet

Providers should now use MCG criteria to support medical necessity for MA prior authorization requests. Familiarity with these guidelines will help ensure efficient submissions and review processes.

We’re committed to keeping you informed as BCBSNE continues the transition to our Medicare Advantage business to P3 Health.

As part of this collaboration, P3 Health is now supporting prior authorization reviews and select clinical decision processes for our members. As this partnership expands across the full Medicare Advantage line of business, we will continue to share updates along the way.

With a transition of this scope, you may notice some evolving processes. As we move forward together, there may be changes in how reviews are conducted and how determinations are communicated, as we align our approaches.

We understand that changes like this can bring questions, and we are committed to working closely across teams—and with you—to keep processes clear, timely, and as seamless as possible.

Providers can also find additional guidance and support resources through our Provider Academy, which offers eLearnings and FAQs to help navigate these updates.

Your feedback is an important part of this partnership. If you are seeing impacts to your team or patients, we encourage you to share your perspective so we can continue to learn and refine our approach together.
 
We greatly appreciate your partnership and the care you provide to our members.

BCBSNE continues preparations for upcoming Medicare Advantage (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 & 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 5/1 status can be viewed within the P3 Provider Portal
• Details for authorization submitted prior to 5/1 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
  • Part B Drug Standard: 72 hours
  • Part B Drug Expedited: 24 hours

Medicare Advantage Expedited Requests: If a request is made or supported by a physician, prescribing physician or other prescriber who indicates that applying the standard timeframe could seriously jeopardize the life or health of the enrollee, or the enrollee’s ability to regain maximum function. 

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 – 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.

Effective immediately, open inpatient Medicare Advantage (MA) authorizations have transitioned to P3 Health for completion.

Authorizations opened prior to 5/1/26 have been transferred and are being closed by BCBSNE, with P3 Health now responsible for completing processing.

If you contact BCBSNE with questions about these authorizations, our teams will reference the pre‑transition authorization list and redirect you to P3 Health as appropriate.

No action is needed from providers at this time, P3 Health will handle all remaining activity for these transferred cases.

To support long-term stability and alignment with CMS Medicare Advantage (MA) guidelines, Blue Cross and Blue Shield of Nebraska (BCBSNE) and our new MA partner, P3 Health*, have evaluated our current hospital settlement processes. As a result, please note that we are discontinuing the following MA settlement processes for in‑network providers, effective 7/1/26:

• MA Critical Access Hospital Cost Settlement for In-Network Providers
• MA Bad Debt Hospital Settlement for In-Network Providers

Through this joint review, BCBSNE and P3 Health assessed current CMS guidance and MA payment design and have determined that these settlement processes are not required. CMS does not require MA plans to replicate Original Medicare’s retrospective cost settlement or bad debt reimbursement processes. MA payments are designed to be prospective and contract-based, providing predictability for providers and members.

 What this change means for you:

• Claims will continue to be paid according to your contracted MA rates
• Reimbursement will remain consistent, timely, and predictable

This update supports a sustainable MA program while continuing our commitment to providing stable reimbursement to our provider partners and supporting access to high-quality care for our members.

* About our new MA partner: P3 Health is a physician-led organization that specializes in Medicare Advantage. They bring hands-on clinical expertise and experience in supporting providers in value-based care. Our partnership with them combines BCBSNE’s strong 87-year track record with the specialized expertise of P3 Health to continue to offer Nebraskans an affordable, high value Medicare Advantage plan.

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

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.

BCBSNE is continuing to strengthen our Medicare Advantage (MA) operations in partnership with P3 Health. These planned enhancements are designed to improve care coordination, streamline processes, and enhance provider support—while maintaining continuity for members and minimizing provider disruption. Below is a high‑level overview of what’s changing and when. Additional details and resources will be shared on NebraskaBlue – Happening Now as effective dates approach.

Key Upcoming Changes

Effective May 1, 2026

• Prior Authorization Submission
  
  • New MA prior authorizations will be submitted through P3 Provider Portal, accessed via NaviNet.
  • Providers will also use P3 Provider Portal to check the status of new authorization requests.
  • Preauthorization phone and fax numbers will remain the same. 
• Care Management, Risk & Quality Programs
  
  • Care management, risk and quality activities for MA will transition to P3 Health.

Effective June 1, 2026

• Medical Necessity Criteria
  
  • MA utilization management criteria will transition from InterQual to MCG (Milliman Care Guidelines).
  • MCG guidelines will be available to providers in NaviNet prior to implementation to support transparency and CMS requirements.

Additional updates may appear across NebraskaBlue online resources as certain MA processes transition to P3 Health. This includes management of MA policies and procedures, management of part B drug prior authorizations and preauthorization services previously supported by Evolent for MSK and IPM. These transitions are operational in nature, and we will continue to communicate details, timelines and any provider impact as more information becomes available.

These enhancements will be implemented in phases throughout 2026. Providers are encouraged to regularly visit NebraskaBlue – Happening Now for the latest updates as effective dates approach.

We updated our Medicare Advantage chiropractic care policy to clarify routine service requirements. Medicare covers spinal manipulation when medically necessary and billed with the correct CPT code and the AT modifier, which should not be used for routine care.

Routine services are not covered by Original Medicare, but BCBSNE Medicare Advantage plans include enhanced routine coverage. Members have a $20 copay per routine visit and receive one set of diagnostic x‑rays per year at no cost when completed by a chiropractor.

For full details, review Policy MA‑X‑082.

To support more accurate STARS quality reporting, we’ve updated how Medicare Advantage (MA) claims containing CPT II codes are processed. CPT II codes are informational quality‑measure codes (such as blood pressure readings or A1c results) and are important for capturing data used in STARS ratings.

What’s Changing
Outpatient institutional claims will no longer be returned when a CPT II code triggers an edit.
Instead:

• The CPT II code will deny at the line level, and
• The rest of the claim will continue to process normally.

This approach allows us to capture quality information without delaying or disrupting payment for covered services.

Critical Access Hospital (CAH) Claims
We are reprocessing previously returned CAH claims affected by this edit to ensure the CPT II information is recorded.

• If a claim was already resubmitted and paid, any additional submissions will deny as duplicates to prevent duplicate payments.

What Providers Need to Do
This update does not require any changes to your current billing practices. This message is for informational purposes only.