Please note: Completing this form will transfer all existing provider agreements. If the form is not signed and/or dated, it will be returned with no further action. Requested effective dates cannot be prior to the date the form is submitted. If no effective date is given or an effective date is requested prior to the date the form is submitted, the assigned effective date will be the date the form was submitted. 

The Provider Add/Extend/Transfer form is used to extend your BCBSNE network status to a new or additional location.

Please note: This form is for use by PHMHP, PLADC, PLCSW, PPhD, PPsyD and RBT Nebraska providers only. Requested effective dates cannot be prior to the date the form is submitted. If no effective date is given or an effective date is requested prior to the date the form is submitted, the assigned effective date will be the date the form was submitted.

The Provisional Provider form is used to add a new provisionally-licensed behavioral health provider and report their supervising practitioner's information. This form can also be used to update the supervising practitioner's information for an existing provisional provider. 

To avoid claim impacts, please do not submit claims for the Provisional Provider until you have received notification the request has been completed. Claims submitted prior to the Provisional Provider being loaded may be processed as out of network or delayed. 

Please allow up to 60 days for completion of this process. 

Email the form to HealthNetworkRequests@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

The NPI Notification form is used to notify BCBSNE of your NPI number(s). This form may be used for your Individual (Type 1) or Organization (Type 2) NPI numbers.

Please allow up to 60 days for completion of this process.

Email the form to HealthNetworkRequests@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

Please note: This agreement is not required for providers using a clearinghouse.

The Trading Partner Agreement is a HIPAA-required business associate agreement between BCBSNE and its trading partners. This agreement is a legally binding contract.

Email the form to ProviderServicesOperationsSupport@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

Important Information
Once the group has become delegated and notice has been sent via email with effective date, the process to submit changes is below:

• Updates must be sent from the approved contact on file via spreadsheet template (please request the template as this can change)
• Delegation updates must be sent via email to delegatednotices@nebraskablue.com; updates are worked in received date order
• Claim submissions should not begin until you receive notification the submission is complete
  • Normally upload is 60 days after submission 
  • Timeline can change – current backlog timeline can be found on NaviNet Plan Central
• Claims submitted prior to receiving notification will be returned
  • Claims cannot process until the information is loaded 
  • If it is preferred to have claims process out of network, claims will need to be dropped to paper and submitted with providers SSN or non-contracted TIN
  • Claims submitted prior to timeline listed on NaviNet will be the responsibility of the provider to resubmit 

Additional Details

• Delegations are required to submit credentialing profiles within 30 calendar days of their committee approval date
• Terminations must be submitted within 5 business days
• Responses to inquiries for information must be submitted within 14 calendar days
  

Please note: Requests must include a voided check and/or bank letter to complete the validation process.

EFT information can be added or updated by completing the Electronic Funds Transfer Enrollment Request form.

To cancel your EFT enrollment, please send an email to ProviderServicesOperationsSupport@NebraskaBlue.com

Please allow up to 10 business days for completion of this process.

Email the form to ProviderServicesOperationsSupport@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

Learn more about Electronic Funds Transfer

The Electronic Remittance Advice Enrollment form is used to enable electronic remittance advice (835). You may also use the form to update your ERA information on file.

Please allow up to 10 business days for completion of this process. 

Email the form to ProviderServicesOperationsSupport@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

Please note: Registration is not required for providers using a clearinghouse.

The Trading Partner Registration form is required to conduct electronic business transactions directly with BCBSNE.   

Please allow up to 10 business days for completion of this process. 

Email the form to ProviderServicesOperationsSupport@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.

Please note: BCBSNE should be notified immediately of all provider terminations. This will allow us to notify impacted members and ensure accurate information is displayed in the Provider Finder.

To terminate a provider or location, please send an email to HealthNetworkRequests@NebraskaBlue.com with the following information:

• Provider name of the provider and/or practice terminating
• Provider NPI
• Tax ID
• Address
• Termination date (month/day/year)

If applicable, please also include the following:

• If you wish to cease participating with BCBSNE at all of your locations. 
• If your contract should be transferred to another group, please indicate which group you are working with so we may coordinate efforts.

For termination requests without a transfer notice to another group, BCBSNE will process the termination and send a letter to all members that have seen the provider in the last 18 months. This applies when the provider is no longer active under an existing agreement at any location.

For termination requests with a transfer notice to another group, BCBSNE will sync with both parties and process the transfer accordingly. A notification is not sent to members. This applies when the provider will remain active under an existing agreement at another location.

If claims were received after the requested termination date, you will be contacted to validate the termination date. We may request corrected claims are submitted. For additional information on submitting the claims, please refer to the General Policies and Procedures Manual.

Please allow up to 15 days for completion of this process. After the termination is processed, please allow up to 24 hours for updates to be displayed in the Provider Finder.

Please note: This form is for use by Nebraska providers only. If you are participating in a PHO, contact your PHO representative to report your changes. Requested effective dates cannot be prior to the date the form is submitted. If no effective date is given or an effective date is requested prior to the date the form is submitted, the assigned effective date will be the date the form was submitted.

Providers may use the Change of Address form to change an address and other demographics such as phone number, email and name (i.e., DBA). When updating mailing address or billing address, please submit a W-9 with the above form.

This form should only be used when keeping the same Tax ID. If you have a new Tax ID and need demographic information updated, please complete the Add/Extend/Transfer Form.

If you have multiple locations, please submit a form for each location. If you have more than 10 locations and need to make the same change for all locations, please complete the Provider Data Updates spreadsheet.

Please allow up to 60 days for completion of this process. After the change is made, please allow up to 24 hours for new information to be displayed in the Provider Finder.

Email the form and/or spreadsheet to HealthNetworkRequests@NebraskaBlue.com

You will receive an email confirmation when your request is received. The email will indicate how long to allow for changes and how to inquire about their status. You will also be notified via email when your request has been completed.