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Below are various printable forms to help with your day-to-day patient care and administration. Find Medicare Advantage Forms »
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| Type | Title | Date | Category |
|---|---|---|---|
 |
Preauthorization Request
Submit this form with medical rationale for preauthorization review of a medical/surgical service. Certain prescriptions may also require a preauthorization. See Pharmacy Management for more. |
1/31/2019 | Preauthorization |
|
Behavioral Health Outpatient Form
This form is required to be submitted for more than 90 visits. |
3/1/2016 | Utilization Management |
|
Psychological/Neuropsychological Evaluation Request
Psych/Neuropsych testing in excess of four hours must be preauthorized using this form. |
3/1/2016 | Utilization Management |
|
Change of Address Form
Providers may use this form to change an address with BCBSNE. If you are participating in a PHO, contact your PHO representative to report your changes. This form is for use by Nebraska providers only. |
1/2/2019 | Administrative and Billing |
|
Coordination of Benefits
Use this form to report other insurance information. It must be completed by the policy holder, but may be submitted by a member or provider. |
1/2/2019 | Administrative and Billing |
|
Check Return Form
Use this form to return an overpayment not already requested by BCBSNE. |
11/6/2001 | Administrative and Billing |
|
Provisional Provider Form
This form is for use by provisionally-licensed behavioral health providers to report their practitioner information and their supervising practitioner's information. This form must be completed and processed before claims can be submitted. This form is for use by Nebraska providers only. |
1/2/2019 | Health Network Administration |
|
Privacy Waiver Form
Use this form when a member requests that a provider restrict the disclosure of PHI to BCBSNE. |
12/10/2013 | Health Network Administration |
|
NPI Notification
Use this form to report your Individual or Organizational NPI number to BCBSNE. This form is for use by Nebraska providers only. |
1/2/2019 | Health Network Administration |
|
Extend-Transfer Existing Agreements
Use this form to extend your network status to a new or additional location. If you are participating in a PHO, contact your PHO representative to report your changes. This form is for use by Nebraska providers only. |
6/5/2017 | Health Network Administration |
|
Trading Partner Registration
This is registration that a provider must complete in order to electronically transact with BCBSNE. Not required for providers using a clearinghouse. |
1/2/2019 | Electronic Data Interchange |
|
Trading Partner Agreement
This is a HIPAA-required business associate agreement between BCBSNE and its trading partners. This agreement is a legally binding contract. Not required for providers using a clearinghouse. |
4/15/2004 | Electronic Data Interchange |
|
Electronic Remittance Advice Form
Use this form to enroll in our Electronic Remittance Advice (ERA) service. You can also use this form to update your ERA information already on file. |
1/2/2019 | Electronic Data Interchange |
|
Reconsideration Request Form (Fillable)
Use this form to submit a corrected claim. |
4/4/2019 | Claims and Benefits |
|
Appeal Request Form (Fillable)
Use this form to appeal a claim determination. |
4/4/2019 | Claims and Benefits |
|
Obstetrical Needs Assessment
Use this form to let us know about any gaps in care you may have closed. |
12/8/2015 | Claims and Benefits |
|
Appeal Request Form
Use this form to appeal a claim determination. |
1/31/2019 | Claims and Benefits |
|
Reconsideration Request Form
Use this form to submit a corrected claim. |
1/31/2019 | Claims and Benefits |
|
CMS 1500
A blank copy of the standard paper claim form to bill Medicare fee-for-service providers. The electronic version is the 837P. |
3/8/2019 | Policy and Procedure Documents |
|
Filing Dental Charges on a CMS 1500
The following document represents the minimal information required for filing medical services provided by a dentist on the CMS 1500 claim form. |
3/8/2019 | Policy and Procedure Documents |
|
Check Replacement Form
Required for missing checks only. |
4/8/2019 | Administrative and Billing |