Appeals

Appeal denial reviews include, but are not limited to, claims that were denied for:

• 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. Please send your requests for these denials on the following forms. These forms can be found at NebraskaBlue.com/Providers/Find-a-Form.

• For claim timely filing denials, submit a Timely Filing Override Request Form. 
• For coordination of benefits denials and workers’ compensation denials, submit a Reconsideration Request Form. 

Provider contract disputes are not an appeal review. These requests can be submitted on the Reconsideration Request Form found at NebraskaBlue.com/Providers/Find-a-Form.

• For provider pricing/contract disputes and issues, submit a Reconsideration Request Form.

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.

Providers can submit a denied claim appeal online via NaviNet^®. 

Appeal fillable and non-fillable forms can be found at NebraskaBlue.com/Providers/Find-a-Form. These forms can be faxed or mailed to the following:

• Fax to 402-548-4684 or 888-492-4944  
  or 
• Mail to  
  Blue Cross and Blue Shield of Nebraska 
  Appeals Department 
  P.O. Box 3248 
  Omaha, NE 68180-0001 

1^st Level Appeals:

BCBSNE Provider Correspondence
PO Box 21501
Eagan, MN 55121

Fax: 210-579-6930

2^nd Level Appeals:

BCBSNE Appeals & Grievances
PO Box 21831
Eagan, MN 55121

Fax: 1-877-482-9749

For additional information regarding Nebraska Medicare Advantage plans, refer to the Medicare Advantage policy page.

How do I check the status of an appeal? 
To check the status of an appeal, call the phone number located on the back of the member’s BCBSNE ID card.  

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

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

What happens if the appeals process has been exhausted?  
BCBSNE will send a letter to the member and provider if all appeal options have been exhausted.  

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