Medicare Advantage

Effective Aug.1, 2025

This announcement is intended to clarify the purpose and intent of BCBSNE’s policy regarding auto-approval for SNF admissions which was initially posted Dec. 6, 2024, and effective Jan. 1, 2025.

• The policy only applies to participating (PAR) Medicare Advantage providers
• It does not apply to non-participating providers or to swing bed stays
• The auto-approval period is being adjusted from seven (7) to three (3) days
• BCBSNE is updating its systems to ensure consistent and accurate application of the policy

What to Expect:

• Auto-approval of the first seven days will apply only to MA Participating (PAR) Skilled Nursing Facilities
• Consistent with the policy, swing bed stays are not eligible for auto-approval (regardless of how authorizations may have been processed in the past)
• Providers must follow the required notification and review steps to maintain eligibility - MA Auto Approval for SNF Admissions - MA-X-093
• Effective Nov. 1, 2025, auto-approval will change from 7 days to 3 days

Reminder of Requirements

Notification of Admission

• Must be submitted within 72 hours of admission
• Preferred method: Submit via NaviNet to initiate authorization and enable continued stay review access
• Alternative methods:
  • Fax: 1-866-422-5120
  • Phone: 1-877-399-1671

Concurrent Authorization Review

• Required to certify additional days beyond the initial seven
  • Effective November 1, this will change to certification beyond the initial three days
• Ensures timely issuance of the Notice of Medicare Non-Coverage to both the facility and the member
• If you are faxing medical records, please send by noon on the due date to maintain review timeliness

We appreciate your cooperation. This clarification is designed to support a more consistent, accurate and efficient application of the policy and overall authorization process. Thank you for your continued partnership.

For BCBNE Medicare Advantage members with the YMA4 or Y2M4 prefix, timely filing denial appeals must be submitted using the Appeal option in NaviNet. Please be advise that paper submissions will not be reviewed.

This process is the same as the one currently used for commercial members.

Providers can now view 2024 MA claims through the Claim Status tool in NaviNet.

To access claim details, please use the member’s 2024 ID number, which includes one of the following four-letter prefixes:

• YMAN
• Y2MN

Using the correct member ID ensures accurate claim lookup and helps streamline your workflow.

Beginning August 1, 2025, BCBSNE MA claims for readmissions will follow the CMS guidelines denying the second readmission. 

Please view the MA Readmission Quality Program procedure for more information. 

At Blue Cross and Blue Shield of Nebraska, we are committed to working with our provider community as partners in health care.

Our new Reimagine Preauthorization page will keep you updated on how we're improving our preauthorization processes. Check back often to stay informed on the changes that matter most to you.

Together, we're reimagining the future of preauthorizations.

To ensure timely and accurate processing of Medicare Advantage (MA) dental claims submitted on behalf of members, please use the official 2025 Dental Reimbursement Form, available under the Provider MA Forms page on NebraskaBlue.

Kindly discontinue the use of outdated ADA claim forms. Utilizing the correct and current form helps streamline the reimbursement process and significantly improves turnaround times.

Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to transparency and keeping our providers informed. We are reaching out to notify you of significant changes and updates to the CMS RADV auditing process. Your support in providing medical records will be crucial as we navigate these changes.

Key Update:

On May 21, 2025, CMS announced a dramatic expansion of its RADV audit program that will affect all Medicare Advantage plans. This represents the most significant change to RADV auditing in the program's history.

What's Changed:

• Annual Audits: CMS will now audit all eligible MA contracts annually (previously ~60 contracts per year).
• Increased Sample Sizes: Audit sample sizes will increase from 35 to up to 200 member records per contract.
• Expedited Completion: CMS is expediting the completion of all audits for Payment Years 2018-2024 by early 2026.
• Expanded Workforce: The agency is expanding its medical coder workforce from 40 to 2,000 coders by September 2025.
• Enhanced Technology: Enhanced AI technology will be deployed to identify potentially unsupported diagnoses.

Although these audits are on the Medicare Advantage Organization, upon request, BCBSNE will need your support in providing medical records.

Thank you for your continued partnership and cooperation.