Provider FAQs

• For Appeals Submitted via NaviNet^®: You can check the status directly in NaviNet.
• For Appeals Submitted Using the Appeal Request Form: Call the phone number located on the back of the member’s BCBSNE ID card.
  

No, BCBSNE’s appeals department does not conduct peer-to-peer reviews. 

Appeal denial letters will advise the member and the provider if additional appeal options are available and how to submit the request. 

BCBSNE will send a letter to the member and provider if all appeal options have been exhausted.  

Yes, BCBSNE’s appeals department will review Department of Correction members if the denial is provider liability.

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 via NaviNet^®.
• 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.

For out of state providers who are unable to access NaviNet please contact member services on the back of the member's ID card.

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.