Provider FAQs
Medicare Advantage (MA) Medical Pharmacy Prior Authorization Program
Below you'll find answers to the questions we get asked the most.
Prior authorizations are required for medications administered at the following places of service:
- Physician Office (POS 11)
- In Home (POS 12)
- Outpatient Facility (POS 19, 22)
- Inpatient CAR-T (POS 21)
Providers directly contracted with Blue Cross and Blue Shield of Nebraska (BCBSNE) may request non-urgent authorizations on the Prime secure provider portal at GatewayPA.com. Providers may also call Prime for authorization requests at the toll-free phone number 800-424-1709. Hours of operation are Monday-Friday from 8 a.m. - 6 p.m. EST for routine requests, and 24 hours per day/seven days per week for urgent requests.
To expedite prior authorizations, the provider should have the following information:
- Member name, date of birth and ID number
- Health plan name
- Member height and weight
- Ordering provider name, tax ID number, NPI, practice address and office telephone and fax numbers
- Rendering provider name, tax ID number, NPI, practice address, and office telephone and fax numbers (if different from ordering provider)
- Requested medication name or HCPCS code
- Anticipated start date of treatment
- Dosing information and frequency
- Diagnosis (ICD-10 code)
- Any additional clinical information pertinent to the request
If requested by Prime, the provider should be prepared to upload the following documents to the Prime provider portal, or to fax the following documents to Prime HIPAA-compliant fax: 888-656-6671.
- Clinical notes
- Pathology reports
- Relevant lab test results
Please note: It is the responsibility of the ordering provider to obtain prior authorization before services are provided. If the ordering provider and the rendering provider are different, the rendering provider is responsible for ensuring that the appropriate approval is on file prior to rendering services.
Providers directly contracted with BCBSNE may request access to the Prime provider portal. To do so, visit Prime provider portal at www.GatewayPA.com and complete the following steps:
- Click on New Provider Access Request under the sign in box.
- Complete the form and click “Register”.
Please have the following information ready:
- Requestor’s name, email address and phone number
- Health plan name
- Provider, facility or group name
- Provider, facility or group service address
- Tax ID number
- NPI
- Practice Administrator name and email address (if not the requestor)
- You can send a message to Prime through the provider portal if the provider is directly contracted with BCBSNE.
- If it is an urgent request, you can call Prime toll-free at 800-424-1709.
Yes. In most cases, approvals can be made based on the initial information provided to Prime by the requestor. If there is a question or concern regarding the information provided, the case will be sent to a pharmacist who will reach out to the requesting provider. If the pharmacist cannot reach an agreement regarding the appropriate course of treatment with respect to the requested medication, the case will be escalated to a Prime physician. A Prime physician will discuss the case with the provider. They will make a mutual decision, in accordance with plan guidelines, on an appropriate course of action.
The ordering provider, rendering provider (if different from ordering) and member receive copies of the final determination notices.
Approvals are valid for all network providers who share the TIN on the authorization.
The outpatient facility will receive a copy of the approval letter and can view the status of the approval via Prime’s provider portal GatewayPA.com.
After an approval is generated, a change in dose and/or frequency may be requested via phone by Prime toll-free at 800-424-1709.
The approval duration or validity period of a prior authorization is dependent on the medication and is not negotiable.
There is one prior authorization number per medication. However, Prime can process multiple requests via a single portal session or telephone call.
Prime has been engaged only to oversee utilization management. Claims should be submitted to BCBSNE.
No. Prior authorization review with Prime is not required when BCBSNE is designated as secondary to other insurance coverage.
For more information about prior authorizations, providers can call Prime toll-free at 800-424-1709.