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Member Forms

Q: What is 1095 form?

A: The Affordable Care Act (ACA) requires everyone to have minimum essential health insurance coverage, or you may have to pay a financial penalty imposed by the Internal Revenue Service (IRS). You will need to provide proof of coverage when you file your Federal Income Tax return. We will provide you a 1095 tax form which should be used when filing taxes to prove that you and/or your dependents had minimum essential health insurance coverage.

Q: When will I receive the form?

A: By January 31, fully insured members should have received an IRS 1095 form listing the individuals who had health insurance coverage.

At this time, the form is not available online but you can request a duplicate by calling the number on the back of your ID card and follow the prompts.

Note: If you obtained coverage through the Federal Marketplace, the 1095-A form will be sent to you from the Marketplace.

Q: Why am I being asked for my (or a family members) Social Security number?
A: Blue Cross Blue Shield of Nebraska is required to report certain member information each year to the IRS, which includes:
  • Name, Address, and Tax Identification Number (TIN) of the contract holder [Your Social Security Number (SSN) is commonly used as your TIN.]
  • Name and TIN of each dependent who is covered under your plan.
  • For each member covered under your plan, the months each of you has been enrolled in your plan.
  • Name, Address, and Employer Identification Number (EIN) of the entity that sponsors your health insurance coverage.

We will use this information to report to the IRS and prepare your individual 1095 tax form.

For more information regarding the 1095 form please view the links below:
Download the Application for Continuity of Care here:
Application for Continuity of Care

Continuity of Care is a service that enables Blue Cross and Blue Shield of Nebraska (BCBSNE) enrollees to receive time-limited care for specified medical conditions from a non-contracted physician at in-network levels of benefits. Continuity of Care eligibility is based on qualifying events listed in the application.  

Download the COB form here:
Coordination of Benefits (COB) (Non-fillable)
Coordination of Benefits (COB) (Fillable)
Coordinación de Beneficios (COB) (No rellenable)
Coordinación de Beneficios (COB) (Rellenable)

Not completing the COB form can result in claim payments being delayed or denied.

Some members have more than one health care coverage for themselves, spouse and dependents. This may include coverage from a spouse's employer, an additional individual policy, Medicare or other insurance plans. One plan becomes your primary plan. It pays your claims first. Then the second plan may pay toward the remaining costs, depending on the plan. This process is called coordination of benefits (COB).

COB provisions allow health plans to work together to help reduce your out-of-pocket expenses for medical, dental and pharmacy claims.

Every policyholder MUST complete the COB form

Frequently Asked Questions

Q: Why do members need to complete the COB form?

A: Many members have other health and dental care coverage in addition to their Blue Cross Blue Shield of Nebraska (BCBSNE) coverage. In order to accurately process your claims, we must have information on any additional coverage you or your dependents may have besides your Blue Cross and Blue Shield of Nebraska policy. For example, many members have coverage through a working spouse or a second employer, or special situations may exist for dependent children who have different health care coverage because of their parents' divorce or separation.

Q: Why does BCBSNE need this information?

A: Up-to-date information helps us process your claims faster, and it can reduce your out of pocket costs. When you have more than one health and dental benefit plan, we coordinate with your other health care carrier to ensure that claims are paid accurately.

Q: I only have Medical coverage with BCBSNE and Dental with another carrier, why do you need to know about my dental coverage?

A: We are asking if you have any additional coverage to what you have with BCBSNE. If you do not have additional medical coverage, then you would indicate on the form that you have no other insurance. Same applies to dental, we are only looking for additional coverage you have to the coverage you have with BCBSNE.

Q: Are members required to provide this information?

A: Yes. We need to know only about other coverage that is in effect while you are covered by BCBSNE. We may withhold payment on claims, pending confirmation of your other coverage information.

If you don't have other coverage, please indicate that on the form and return it to us.

Q: I am covered by two Blue Cross plans. Do I need to complete this form?

A: Yes. If you are covered by a second Blue Cross benefit plan, you must provide this information.

Q: I am no longer covered by BCBSNE. Do I still have to respond?

A: Yes, if your BCBSNE coverage was in effect at any time during the past 18 months. We need to know about other coverage that was in effect while you were covered by BCBSNE. We don't need to know about any coverage that started after your BCBSNE coverage ended.

Q: I am single, and I have no children. Why are you asking about my spouse and children?

A: This questionnaire is used for all BCBSNE members, regardless of whether they are single or married, or whether they have children. You need to answer only the relevant questions.

Q: I have other insurance but I choose not to use it. Do you still need the information?

A: Yes. We need to know about all other coverage that you or any of your covered dependents may have.

Q: I have additional questions. Where do I get answers?

A: For questions about your coverage, call the number on the back of your member ID card.

Q: Where can I fax the COB form or additional documents?

A: Fax the completed form and any documents to: 402-392-4126.

Q: Where can I mail back the COB form?

A: Please mail to:
Blue Cross Blue Shield of Nebraska
PO BOX 3248
Omaha, NE 68180

Affidavit for Transfer of Personal Property
Debit Authorization (Non-fillable) (for Medicare Supplement members only)                 
Debit Authorization (Fillable) (for Medicare Supplement members only)
Farm Bureau debit authorization (for Medicare Supplement plans effective before January 1, 2014)
Check Replacement Form (Non-fillable)
Check Replacement Form (Fillable)

You have multiple payment options to make it easy and convenient to pay your premiums. Learn more.