Network Termination – Second Level of Appeal

A second-level appeal is available only to participating providers whose participation or payable status in the plan networks is being terminated for cause.

Note: Providers that leave a delegated credentialing arrangement will be treated as new applicants and therefore will only be eligible to receive one level of appeal if network participation is denied.  

The second-level appeal request must be made in writing and submitted to Blue Cross and Blue Shield of Nebraska (BCBSNE) within 60 calendar days of the date of the Hearing Committee’s decision letter or completion of the corrective action plan. BCBSNE will furnish written notice of the date and time of the hearing within 60 calendar days of receiving the appeal request. The hearing will be held at BCBSNE’s offices in Omaha, Nebraska, or virtualas soon as reasonable arrangements can be made. The hearing will be conducted not more than 75 calendar days from the date the appeal request was received unless the provider or Hearing Committee is unable to participate within that timeframe. In this case, the hearing will be held within 120 calendar days of the request.

The second-level Hearing Committee members will consist of one person selected by each party to the appeal and one individual mutually agreeable to both parties. At least one member of the committee shall be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute. The first-level Hearing Committee panel members may not participate in the second-level appeal hearing. The Chief Medical Officer (CMO) or designee will serve as chairperson for the second level hearing but shall not vote in the decision of the Hearing Committee. Each party pays costs for the person it selected and shares the costs of the third. Costs are not recoverable. 

Minutes of the hearing are recorded and made available to the provider upon written request.  

Within 60 calendar days of the final adjournment of the hearing, the Hearing Committee shall decide. A majority vote is required to overturn the original adverse recommendation. The VP of Provider Services or designee shall promptly notify the provider by certified mail or other traceable means, of the decision or the Hearing Committee and the action be taken as a result of such decision.

Note: The provider’s right to a hearing will be forfeited if the provider fails, without good cause, to appear at the scheduled hearing of either the first- or second-level appeal or if the provider fails to participate in good faith in the appeal and fair hearing process. In such cases, the original adverse recommendation will stand as the final decision.