Non-Contracted Provider Appeals

Overview 
CMS has specific processes that non-contracted Medicare health care providers must follow if they disagree with a claim determination made by Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage plans. This policy outlines how to submit claim payment disputes and payment reconsideration (appeal) requests, in accordance with Medicare guidelines. 

Payment Reconsideration (Appeal) Requests
If a claim is denied or paid at a different level than billed, non-contracted providers may request a payment reconsideration — the first step in the Medicare appeal process. 

Filing Deadline 
Appeals must be submitted within 65 calendar days from the date of the remittance notification. 

Required Documentation

• A statement explaining the reason or factual basis for the appeal 
• Any supporting documentation, including clinical records 
• A Waiver of Liability Statement signed by the provider 
• If submitted after the 65-day deadline, documentation supporting the reason for untimely filing 

Submission Instructions 
Use the same contact information as listed above for disputes. 

BCBSNE will review and respond to completed appeal requests within 60 calendar days. If the denial is upheld, BCBSNE will forward the case to the CMS Independent Review Entity (IRE) for a second-level review. The IRE will issue a resolution to both the provider and BCBSNE. 

Appeals Involving LCD/NCD Denials 
If a denial is based on a Local Coverage Determination (LCD) or National Coverage Determination (NCD), providers may include:

• References to applicable LCDs/NCDs 
• Clinical documentation supporting how the service meets coverage criteria 
• Peer-reviewed literature or clinical guidelines, if applicable 

If the denial is upheld and the provider believes the LCD/NCD was misapplied, the case may be escalated through CMS or the Medicare Administrative Contractor (MAC). 

Medicare Advantage Member Rights 
While non-contracted providers may appeal claim denials, Medicare Advantage members also have the right to appeal coverage decisions. Providers may assist members by: 

• Informing them of their appeal rights 
• Providing supporting documentation 
• Directing them to BCBSNE Member Services or Medicare