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Medical Policy Updates Effective 11/15/2026
Act
by Nov 15, 2026
Effective date
Nov 15, 2026
Identified
Sep 5, 2026
Summary
Blue Cross Blue Shield of Nebraska implemented two major medical policy updates effective 11/15/2026: (1) New quantity limits capping Physical Therapy, Occupational Therapy, and Speech Therapy at 25 hours per week each, and (2) Revised autism spectrum disorder coverage requiring prior authorization with stricter documentation, assessment, and progress criteria for ABA services. Both policies establish new preauthorization and documentation requirements that will impact claim processing and provider billing workflows.
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What to do
by Nov 15, 2026 · 10 steps
01BILLING TEAM: Update billing system to enforce maximum 25 hours per week caps for CPT codes related to PT, OT, and ST services.
02Configure system to calculate weekly maximums over 7-day periods independently for each therapy discipline and flag claims exceeding limits for denial.
03PRIOR AUTH TEAM: Update preauthorization requirements—autism spectrum disorder (ASD) coverage now requires prior authorization (previously did not).
04Develop prior auth checklist requiring: diagnosis confirmation by licensed professional, current ABA referral within 3 years, structured assessments (parent interviews, behavioral observations in 2+ settings, evidence of repetitive/restricted behaviors), age-appropriate treatment goals (25 hours/week max), individualized treatment plan with measurable goals, provider credentials verification (LBA/BCBA/licensed psychologist), and supervision documentation (minimum 25% for CBAA/BCaBA).
05BILLING TEAM & PROVIDERS: Implement mandatory documentation collection for all ABA claims: initial assessment, individualized treatment plan with measurable goals organized by Communication/Behavior/Social/Academic domains, progress data (ABLLS, VB-MAPP, or equivalent), provider qualifications, treatment setting/participants, clinical linkage to active ASD symptoms, and transition/aftercare planning.
06COMPLIANCE TEAM: Establish reassessment triggers—require new assessments and goals if patient absent >60 days.
07For continuation of treatment, require documentation every 6 months showing 50% mastery of stated goals, evidence of skill generalization across settings, and progress bridging chronological/developmental age gap.
08PROVIDERS: Ensure ABA treatment plans include group therapy justification with age/developmental appropriateness documentation if group services requested.
09Claims lacking required documentation or exceeding 25 hours/week will be denied.
10CPT 97155 and 97156 are payable only as telehealth per state mandate.
Codes mentioned
9715597156
Original notice
Medical Policy Updates Effective 11/15/2026
nebraskablue.com · Always check the source before changing claims.