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 the P3 Provider Portal via NaviNet. 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.

Yes, NaviNet will guide providers to the appropriate prior authorization workflow based on the line of business.

Effective May 1, 2026, all MA medical and medical pharmacy prior authorization requests must be submitted through the P3 Provider Portal. 

Providers will continue to access prior authorizations through single sign-on (SSO) from NaviNet, which now includes two distinct options: 

• Commercial Prior Authorization 
• Medicare Advantage Prior Authorization 

Selecting Medicare Advantage Prior Authorization will route providers directly into the P3 Provider Portal to submit and manage all MA prior authorization requests. 

The following MA prior authorization requests are included in the P3 Provider Portal:

• Medical Prior Authorizations, including inpatient admissions 
• Musculoskeletal (MSK) and Interventional Pain Management (IPM) requests  
  
  • Previously submitted through Evolent 
• Medical Pharmacy prior authorizations for Medicare Advantage Part B medications  
  
  • Previously submitted through OptimizeRx via the GatewayPA portal 

All of these request types will now be submitted and tracked within P3, providing a single, centralized MA authorization workflow. 

An eLearning module is available to guide providers on submitting requests, searching existing authorizations, and uploading medical records in the P3 portal. 

Prior authorizations will carry over as part of the P3 Health transition effective May 1, 2026. A new authorization is not required solely because dates of service extend into May 2026. 

Effective immediately, open inpatient MA authorizations have transitioned to P3 Health for completion. 

• Authorizations opened prior to May 1, 2026 
  
  • For open inpatient MA authorizations these have been transferred to P3 Health and are being closed by BCBSNE, with P3 Health now responsible for completing all remaining processing. 
  • For all other authorizations continue to check the 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 
  
  • Status should be checked in the P3 Provider Portal, which is accessible via NaviNet single sign-on (SSO) once live. 

If you contact BCBSNE with questions regarding an open inpatient authorization submitted prior to May 1, 2026, BCBSNE teams will reference the pre‑transition authorization list and redirect providers to P3 Health as appropriate. 

No action is needed from providers at this time. P3 Health will handle all remaining activity for transferred authorizations, including those with dates of service extending beyond May 1, 2026. g existing authorizations, and uploading medical records in the P3 portal. 

Yes. An authorization can be submitted, but it’s important to include clinical documentation. P3 Health Utilization Management (UM) will complete the review. 

No. Once submitted, an authorization cannot be amended; however, additional clinical documentation may be added.

No. There is no draft‑saving feature available.

Each denial will include specific instructions for peer‑to‑peer review and appeals.

No. Backdating authorizations is not allowed.

Yes. BCBSNE will continue to conduct retro reviews.

No, the payer ID will not change.

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.