CommercialPrior AuthHigh impact
Medical Policy Updates Effective 11/15/2026
Blue Cross Blue Shield of Nebraska·NE · Physical Therapy, Occupational Therapy, Speech Therapy +2 more·Medical Policy
Effective date
Nov 15, 2026
We identified it
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.
Action Required
By November 15, 2026: (1) BILLING TEAM: Update billing system to enforce maximum 25 hours per week caps for CPT codes related to PT, OT, and ST services. Configure system to calculate weekly maximums over 7-day periods independently for each therapy discipline and flag claims exceeding limits for denial. (2) PRIOR AUTH TEAM: Update preauthorization requirements—autism spectrum disorder (ASD) coverage now requires prior authorization (previously did not). Develop 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). (3) BILLING 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. (4) COMPLIANCE TEAM: Establish reassessment triggers—require new assessments and goals if patient absent >60 days. For 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. (5) PROVIDERS: Ensure ABA treatment plans include group therapy justification with age/developmental appropriateness documentation if group services requested. Claims lacking required documentation or exceeding 25 hours/week will be denied. CPT 97155 and 97156 are payable only as telehealth per state mandate.