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Medical Policy Updates Effective 11/15/2026
Effective date
Nov 15, 2026
Identified
Oct 10, 2026
Summary
Blue Cross and Blue Shield of Nebraska (BCBSNE) is implementing two medical policy changes effective 11/15/2026: (1) a new quantity limit policy (I.222) capping physical therapy, occupational therapy, and speech therapy at 25 hours per week per discipline, and (2) a revised autism spectrum disorder policy (I.178) with enhanced documentation, preauthorization, and clinical criteria for ABA services. Both policies require billing and clinical teams to implement new authorization, documentation, and coverage verification workflows.
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What to do
Action · 12 steps
01By 2026-11-15, billing and clinical teams must implement the following changes for BCBSNE members in Nebraska.
02For Policy I.222 (Therapy Services): Update billing system to enforce maximum weekly limits of 25 hours per week independently for each therapy discipline (PT, OT, ST), calculated over a seven-day period.
03No preauthorization is required, but claims exceeding these limits should be flagged and denied.
04Verify patient eligibility and cumulative weekly hours before claim submission.
05For Policy I.178 (Autism Spectrum Disorder): Implement mandatory preauthorization workflow for all ABA (applied behavior analysis) services.
06Require providers to submit comprehensive documentation including: structured behavioral assessments, diagnosis confirmation from licensed provider, individualized treatment plan with measurable goals, baseline and progress data using standardized assessments (ABLLS, VB-MAPP or equivalent), provider credentials (LBA, BCBA, or licensed psychologist), and transition/aftercare planning.
07Enforce the 25 hours per week maximum for ABA services.
08Establish 60-day absence re-assessment triggers requiring new evaluations and goals.
09Implement 6-month reassessment requirement for continuation of ABA services and require demonstration of 50% goal mastery for ongoing coverage.
10Configure system to deny continuation requests lacking progress documentation or showing plateaued/declining scores.
11Update prior auth denial templates to reference peer review process and behavioral improvement thresholds.
12Staff processing ABA requests should verify provider licensing credentials match state law and benefit plan requirements.
If missed: Failure to obtain preauthorization for ABA services will result in claim denial; therapy services exceeding weekly maximums will be denied or reduced to policy limits.
Codes mentioned
9715597156
Original notice
Medical Policy Updates Effective 11/15/2026
nebraskablue.com · Always check the source before changing claims.