Medicare Advantage

We updated our Medicare Advantage chiropractic care policy to clarify routine service requirements. Medicare covers spinal manipulation when medically necessary and billed with the correct CPT code and the AT modifier, which should not be used for routine care.

Routine services are not covered by Original Medicare, but BCBSNE Medicare Advantage plans include enhanced routine coverage. Members have a $20 copay per routine visit and receive one set of diagnostic x‑rays per year at no cost when completed by a chiropractor.

For full details, review Policy MA‑X‑082.

To support more accurate STARS quality reporting, we’ve updated how Medicare Advantage (MA) claims containing CPT II codes are processed. CPT II codes are informational quality‑measure codes (such as blood pressure readings or A1c results) and are important for capturing data used in STARS ratings.

What’s Changing
Outpatient institutional claims will no longer be returned when a CPT II code triggers an edit.
Instead:

• The CPT II code will deny at the line level, and
• The rest of the claim will continue to process normally.

This approach allows us to capture quality information without delaying or disrupting payment for covered services.

Critical Access Hospital (CAH) Claims
We are reprocessing previously returned CAH claims affected by this edit to ensure the CPT II information is recorded.

• If a claim was already resubmitted and paid, any additional submissions will deny as duplicates to prevent duplicate payments.

What Providers Need to Do
This update does not require any changes to your current billing practices. This message is for informational purposes only.

Beginning Feb. 26, 2026, pharmacy preauthorization decision letters will be available directly in CoverMyMeds (CMM) for requests decisioned on or after that date. This enhancement gives providers faster access to decision information within the platform they already use.

What to know

• Letters for requests decisioned before Feb. 26 will not appear in CMM
• BCBSNE will continue faxing all decision letters to the ordering physician’s fax number on record
• The BCBSNE preauthorization reference number can be found on the faxed decision letter or through our automated IVR phone system. Please use these resources before contacting Customer Service
• We continue to follow the standard 72‑hour turnaround time for peer‑to‑peer requests

As part of our ongoing effort to simplify processes and reduce administrative burden for providers, BCBSNE is excited to announce a significant update: Beginning March 3, 2026, prior authorization requirements for non‑contrast CT scans will be eliminated across both Medicare Advantage and Commercial lines of business.

This change supports a more seamless experience for members and providers and reflects our continued commitment to thoughtfully reimagining preauthorization.

Why This Matters

• Faster access to care: Providers can schedule non‑contrast CT scans without waiting for approval
• Reduced administrative work: Less time spent on submitting and managing authorizations
• Supports our long‑term vision: We continue to focus on improving processes and removing barriers where appropriate

Important Clarification
This change applies only to non‑contrast CT scans.
If a prior authorization request is submitted for:

• CT with AND without contrast, or
• CT with contrast,
  ➡️ These services will still require prior authorization and medical review.

Rollout Timeline

• Feb. 23: All non‑contrast CT PAs will be approved
• Feb. 26: Code removal begins
• March 2: System updates completed
• March 3: Go‑live - No prior authorization required for non‑contrast CT scans

A system issue was identified in which outpatient mental health claims were being misclassified as PCP claims. This caused incorrect cost‑share amounts to be applied, and the required mental health copay was not assessed. A report of all impacted claims has been generated, and reprocessing is underway.

All impacted claims will be automatically adjusted to apply the correct mental health copay for Medicare‑covered outpatient mental health services, regardless of provider type. No further action is needed from the provider for the claim to be adjusted, and providers are not required to resubmit claims or submit a reconsideration request.

This issue affects dates of service from Jan. 1, 2025, through Nov. 26, 2025. As claim adjustments occur, providers will see the corrected claim activity and the associated recoupment for the $35 mental health copay for each affected date of service. Following the adjustment, providers will then be responsible for billing the member for the applicable copay for each date of service.

As of Jan. 1, 2025, all Medicare Advantage (MA) program operations transitioned fully in-house from Advantasure. Claims with dates of service on or before Dec. 31, 2024 are no longer eligible for reconsideration or adjustment as of Jan. 1, 2026.

Please note that all clean MA claims must be submitted within 120 days of the date of service, or within the timeframe outlined in your provider agreement.

As of Jan. 1, 2026, no adjustments will be accepted for claims with 2024 dates of service — no exceptions. Any claims submitted after Dec. 31, 2025 will be rejected for timely filing.