Provider FAQs

Many MA plans have low out-of-pocket costs and premiums. In many plans, hospitals and providers are paid the same as Original Medicare. MA plans place an emphasis on preventive care and include many benefits not offered by Original Medicare, which have been shown to improve the health and well-being of MA members compared to Original Medicare.

Again, not all MA plans are created equal. Many MA plans do not require referrals to see specialists. MA plans may require prior authorization for some services to ensure the care is medically necessary and the proper payments are made. Many of these controls do not exist in Original Medicare, making health care more expensive overall.

Yes, new cards have begun going out but are NOT effective until 1/1/25.

• YMA4 will be the new prefix for the HMO product instead of YMAN.
• Y2M4 will be the new prefix for the PPO product instead of Y2MN.

Yes, just like our commercial BCBSNE members, the BCBSNE MA member cards will be available on NaviNet.

All MA plans are not the same. Each MA plan is customized by private health insurance companies and follow guidelines provided by the federal government. Most MA plans offer benefits beyond Original Medicare.

Many MA plans provide care using networks of providers and specialists, but all networks are not equal. PPO MA plans allow you to use doctors, hospitals and other health care providers outside the network without a referral.

Many MA plans offer robust travel networks of providers allowing flexibility across the country.

Original Medicare does not pay for the entire cost of care, so costs are passed to the beneficiary. Many MA plans include predictable cost-share amounts in the form of copays or coinsurance for covered Medicare services, which are applicable toward an annual maximum out-of-pocket amount. Original Medicare does not offer the same financial protection.

MA plan benefits can change annually. The Annual Enrollment Period (AEP), which runs from Oct. 15 to Dec. 7 each year, is an opportunity for Medicare beneficiaries to evaluate their plan and determine if changes are necessary for the upcoming year.

Yes, we recently communicated a change in the management of certain drugs under the medical benefit for Medicare Advantage (MA) members. The prior authorization requests can be submitted via web exclusively through GatewayPa.com. The MA Part B drug request form has been retired and you will no longer be able to submit these prior authorizations via fax.

Thank you for your continued support in ensuring our members receive high-quality and clinically appropriate care.

Effective Jan. 1, 2025, BCBSNE began the new process to automatically approve the first 7 days in a Skilled Nursing Facility (SNF) for all MA PAR providers.

Notification of Admission is required within 72 hours of admission.

Notification of Admission:

• Can be provided via NaviNet by submitting an authorization, allowing access to the authorization if a continued stay review is needed.
• If continued stay review is needed, you can access the authorization to conduct your review via NaviNet, but only if the initial review was submitted via NaviNet.

Alternative Notification Methods:

• Fax to the UM fax line: 1-866-422-5120
• Call the UM phone line: 1-877-399-1671

Concurrent Authorization Review:

• Required to certify additional days.
• Ensures timely issuance of Notice of Medicare Non-Coverage to the facility and the member. 
• If faxing the medical records, please fax the documents by noon the day they are due to maintain timeliness of the review.

Yes, this will be extended to the swing bed level of care at CAHs.

All auths for all lines of business are accepted on the auth portal through the providers link on NaviNet. Our preauth tool will be able to look at the LOB the member belongs to and identify if the code/service requested:

1. Needs preauth at all by LOB
2. If it does, it will only bring up the auth types associated with that LOB and walk the user through the appropriate criteria and medical policies that apply to that LOB.

Yes, the auths will be honored and loaded by Blue Cross and Blue Shield of Nebraska (BCBSNE) – but the number WILL change. The claims system will look for the auth in our system and process appropriately.

No, the payer ID will not change.

 They will be on the same remit with the same payment cycle.

Reimbursement is based on your CMS percentage, and we will not be posting the fee schedules. You may access the CMS fee schedules at cms.gov.