Appeals
An appeal is a request from a member or provider for Blue Cross and Blue Shield of Nebraska (BCBSNE) to review a pre- or post-service denial that the provider/member disagrees with based on the information presented. Examples of services that should be submitted for an appeal include those that involved a medical determination but are not limited to medical necessity, medical policy, experimental or investigational determinations.
The specific appeal processes available to a member and the timeframe for requesting and completing an appeal is based on the terms of the member’s individual or group contract with BCBSNE and applicable state and federal laws.
Providers are encouraged to submit any new or additional medical information with the appeal request to avoid a delay in processing the appeal.
Preservice and post service reviews include, but are not limited to:
- Medical necessity
- Investigative
- Cosmetic
- Contract exclusions
- No preauthorization obtained
- Pre-existing
- Medical emergency
- Medical vs. dental
- In-network vs. out-of-network
Expedited or Urgent Appeals: You may request an expedited or urgent appeal verbally or in writing for a medical necessity or investigative determination if it meets the following Department of Labor definition:
- If a denial could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
- In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Standard Appeals: All appeals may be submitted by written documentation (letter or fax). Standard appeals are those that do not meet the expedited/urgent definition and/or are retrospective, post-service claims or may relate to non-urgent prospective, pre-service, admission and observation claims.
Claim timely filing denials, coordination of benefits denials, and workers’ compensation denials are not reviewed by Appeals.
- For Claim Timely Filing Denials: Submit a Timely Filing Override Request.
- For Coordination of Benefits Denials and Workers’ Compensation Denials: Submit a Reconsideration Request.
- For Preservice Review Appeals: Follow the directions on the letter you received.
Claim appeals, timely filing requests and reconsiderations should be submitted via NaviNet®, from the claim status screen. It is crucial to select the correct form. Using the incorrect form can lead to delays and prevent your request from being processed by the appropriate team.
For out-of-network providers, the forms are available on our Provider Forms page.
Provider contract disputes are not an appeal review.
- For Provider Pricing/Contract Disputes and Issues: Submit a Reconsideration Request Form.
Reconsideration requests should be submitted via NaviNet®, from the claim status screen. It is crucial to select the correct request form. Using the incorrect form can lead to delays and prevent your request from being processed by the appropriate team.
For out-of-network providers, the forms are available on our Provider Forms page.
Some medical necessity and investigative appeal reviews are sent to outside organizations, called Independent Review Organizations (IRO). An IRO will conduct an independent review of the adverse determination for eligible appeals.
For out-of-network providers, the forms are available on our Provider Forms page.
Please refer to the Medicare Advantage (MA) BCBSNE Provider Procedure, Contracted Provider Appeals, regarding MA appeals requests.
For additional information regarding BCBSNE MA provider procedures, refer to the BCBSNE Provider Procedures page.