Young girl with a superhero mask and cape sitting on a hospital bed.

Providers

Preauthorization

Protecting members is a top priority. Through research and medical policy, developing and implementing guidelines that encourage member safety continues to be necessary. Utilization management programs, such as pre-service reviews and preauthorizations, provide effective ways to manage member safety and the volume of health care services delivered. BCBSNE has two preauthorization/pre-service programs designed to keep member safety at the forefront. Pre-service reviews allow us to determine if the procedures are medically necessary and/or investigative, according to the stated criteria and medical policy. This preauthorization requirement is applicable to all BCBSNE members (except Medicare Supplement and FEP members).

Access the list of services, procedures and medical policies requiring authorization (certification) prior to providing the service.

Search codes on MedPolicy Blue »

View the Preauthorization List
Updated 3/19/2019

All investigative denials will be considered provider liability, even if a preauthorization is done and denied as being investigative. 

Per our policies and procedures, a provider may hold a member financially liable for a medical necessity or investigative denial only if:

  • The provider has advised the member – prior to services being provided – that he or she may be financially liable for the services provided
  • The provider must give the member an estimate of financial liability

For a situation where a patient requests services considered not medically necessary and/or investigative and agrees in writing to be responsible for the non-covered charges, the provider must file a paper claim with the signed patient waiver. If a claim is filed without a waiver and the claim is denied as provider liability (but a waiver was signed prior to the claim being filed), a provider may submit a reconsideration with the waiver.

If a written agreement cannot be obtained, verbal notification may be given by the provider. The verbal notification must be documented in the patient’s medical records at the time the notification is given, and evidence provided to BCBSNE. For all other balances, the provider agrees not to bill or collect any amount from the member.

In-State Providers
The most efficient way to expedite a preauthorization is to submit your request online. You can also fax your request with medical rationale.

Submit a Preauthorization Online (NaviNet)

Out-of-State Providers
If you are an out-of-state provider, please use the  Preauthorization Request Form for all preauthorizations or call the customer service phone number on the back of the member's BCBSNE ID card.

Tips and resources:
Clear Coverage Frequently Asked Questions
Clear Outpatient Quick Reference Guide

With increased utilization in clinical areas such as hysterectomies and sinus surgeries, there is concern that members may be undergoing unnecessary surgical procedures, which impacts patient safety.

To that effect, BCBSNE requires a preauthorization for BCBSNE members and their dependents (excluding FEP and Medicare Supplement members) for the following procedures:

  • Endometrial ablations
  • Hysterectomy
  • Hysteroscopy
  • Sinus surgeries
Log into NaviNet

In keeping with our commitment to member safety and promoting continuous quality improvement for services, BCBSNE has entered into an agreement with National Imaging Associates, Inc. (NIA), to implement a spine pain management program.  NIA, a Magellan Health Services company, is an industry-leading organization that delivers innovative solutions for effective health care management.

This program includes preauthorization for two components of non-emergent spine care – outpatient interventional pain management (IPM) services, and inpatient and outpatient cervical and lumbar spine surgeries for all BCBSNE members.

Note: The Federal Employee Program, Medicare Supplement, Nebraska Department of Correctional Services, and the Nebraska Department of Health and Human Services are excluded from this program.

BCBSNE oversees the program and continue to be responsible for claims adjudication and medical policies. NIA Magellan will manage non-emergent, outpatient IPM services, along with inpatient and outpatient cervical and lumbar spine surgeries.

Additional resources:

The following radiology services require a preauthorization:
  • Computed Tomography (CT/CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)

Note: Plain radiology films, imaging studies performed in conjunction with emergency room services and inpatient hospitalizations are excluded from this requirement.

Without an approved preauthorization, claims may be denied and you may be responsible for payment of the charges. BCBSNE performs radiology reviews for the following services using Clear Coverage, a web-based preauthorization tool.

Radiology Preauthorization Guide

Log into NaviNet

BCBSNE requires precertification for all acute (non-emergency) inpatient and observation admissions to hospitals or facilities on or before the first day of admission. Unplanned admissions can be submitted the first business day following admission.

To submit a precertification, visit NaviNet or call 800-247-1103.

Log into NaviNet
Additional questions? Read the  Preauthorization FAQs.