Member claims access and prior authorization (PA) reporting
Interoperability — member claims access
Interoperability is a federal rule from the Centers for Medicare & Medicaid Services (CMS), designed to give greater access and transparency across health care systems. Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage and Nebraska HeartlandBlue members who would like electronic access to their medical records, such as claims information, can download the application Care Evolution.
Download Care Evolution
- If you’re a developer and want to learn more about HL7® Fast Healthcare Interoperability Resources (FHIR®) Release 4.0.1. OR The software components and configurations an application must use in order to successfully interact with the API, visit Supported FHIR Resources.
- If you want to learn more about OpenID Connect Core 1.0, incorporating errata set 1. OR All applicable technical requirements and attributes necessary for an application to be registered with any authorization server(s) deployed in conjunction with the API, visit Developer Overview.
- If you want to learn more about API syntax, function names, required and optional parameters supported and their data types, return variables and their types/structures, exceptions and exception handling methods and their returns, visit https://api.bcbsnefhir.com/r4/metadata.
- For sample cURL requests and other example queries, visit API References.
Prior authorization metrics for medical items and services (excluding drugs)
To comply with the CMS Interoperability and Prior Authorization final rule, BCBSNE is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs and payers. For questions on the data below, contact:
Qualified Health Plans (QHP): QHPPriorAuthMetrics@NebraskaBlue.com
Medicare Advantage (MA): MAPriorAuthMetrics@NebraskaBlue.com
Reporting period:
QHP 2025 Medicare Advantage 2025
For the 2025 reporting period, MA Plans and QHP must have prior authorization decisions sent within:
- 72 hours for expedited requests (urgent)
- 14 calendar days for MA standard requests (non-urgent)
- 15 calendar days for QHP standard requests (non-urgent)
Beginning Jan. 1, 2026, the CMS Interoperability and Prior Authorization final rule requires MA Plans and QHP to send prior authorization decisions within:
- 72 hours for expedited requests (urgent)
- 7 calendar days for standard requests (non-urgent)
These are the medical items and services for which we require prior authorization (excluding drugs):
QHP Preauthorization
Medicare Advantage Medical Prior Authorization
QHP 2025**
|
Standard PA requests (response due within 15 days) |
Expedited PA requests (response due within 72 hours) |
||||
| QHP products |
|||||
| Request approved |
89% |
95% |
|||
| Request denied |
9% |
5% | |||
| Request approved after time for review was extended* |
N/A |
N/A | |||
| Request approved after appeal |
1% |
0% |
|||
|
Standard PA Requests |
|
| QHP Products | |
| Request Approved | 89% |
| Request Denied |
9% |
| Request approved after time for review was extended* |
N/A |
| Request Approved after appeal |
1% |
|
Expedited PA Requests |
|
| QHP Products | |
| Request Approved |
95% |
| Request Denied |
5% |
| Request approved after time for review was extended* |
N/A |
| Request Approved after appeal | 0% |
**Percentage may not equal 100% due to rounding.
| QHP products Time between receiving PA request and decision |
||
| Mean (average) time | Median (middle) time | |
| Standard (days) |
7 | 4 |
| Expedited (hours) |
15 |
1 |
Medicare Advantage 2025**
|
Standard PA requests (response due within 14 days) |
Expedited PA requests (response due within 72 hours) |
||||
| MA HMO products |
MA PPO products | MA HMO products |
MA PPO products |
||
| Request approved |
95% |
95% |
98% | 98% | |
| Request denied |
4% |
4% |
2% | 2% | |
| Request approved after time for review was extended* |
N/A |
N/A |
N/A | N/A | |
| Request approved after appeal |
1% |
1% |
0% | 0% | |
|
Standard PA Requests (response due within 14 days) |
||
| MA HMO Products |
MA PPO Products | |
| Request Approved |
95% |
95% |
| Request Denied |
4% |
4% |
| Request approved after time for review was extended* |
N/A |
N/A |
| Request Approved after appeal |
1% |
1% |
|
Expedited PA Requests (response due within 72 hours) |
||
| MA HMO Products |
MA PPO Products | |
| Request Approved |
98% |
98% |
| Request Denied |
2% |
2% |
| Request approved after time for review was extended* |
N/A |
N/A |
| Request Approved after appeal | 0% |
0% |
**Percentage may not equal 100% due to rounding.
| Time between receiving PA request and decision | ||||
| MA HMO products | MA PPO products | |||
| Mean (average) time | Median (middle) time | Mean (average) time | Median (middle) time | |
| Standard (days) |
2 |
1 |
3 | 1 |
| Expedited (hours) |
10 |
1 |
11 | 1 |
| MA HMO products Time between receiving PA request and decision |
||
| Mean (average) time | Median (middle) time | |
| Standard (days) |
2 |
1 |
| Expedited (hours) |
10 |
1 |
| MA PPO products Time between receiving PA request and decision |
||
| Mean (average) time | Median (middle) time | |
| Standard (days) |
3 | 1 |
| Expedited (hours) |
11 | 1 |