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Below are various printable forms to help with your day-to-day patient care and administration. Find Medicare Advantage Forms »
To download forms 1) right click on PDF 2) Select "save target as" in Internet Explorer or "save link as" in Chrome 3) Save it to your machine 4) Open the file in this saved location.
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| Type | Title | Date | Category |
|---|---|---|---|
 |
Psychological/Neuropsychological Evaluation Request
Psych/Neuropsych testing in excess of four hours must be preauthorized using this form. |
3/1/2016 | Utilization Management |
|
Behavioral Health Outpatient Form
This form is required to be submitted for more than 90 visits. |
3/1/2016 | Utilization Management |
|
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 |
|
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 |
|
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 |
|
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. |
5/5/2020 | Health Network Administration |
|
Appeal Request Form (Fillable)
Use this form to appeal a claim determination. |
4/4/2019 | Claims and Benefits |
|
Preauthorization Request
Submit this form with medical rationale for preauthorization review of a medical/surgical service if you are located outside of Nebraska. Be sure to "save as" after you have filled out the form. Certain prescriptions may also require a preauthorization. See Pharmacy Management for more. |
1/31/2019 | Preauthorization |
|
Check Return Form (Non-fillable)
Use this form to return an overpayment not already requested by BCBSNE. This version does not have fillable fields. |
11/23/2020 | Administrative and Billing |
|
Provisional Provider Form (Non Fillable)
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. |
1/6/2021 | Health Network Administration |
|
Provisional Provider Form (Fillable)
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. |
1/6/2021 | Health Network Administration |
|
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 |
|
Check Replacement Form
Required for missing checks only. |
8/3/2020 | 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 |
|
Trading Partner Registration (Fillable)
This is registration that a provider must complete in order to electronically transact with BCBSNE. Not required for providers using a clearinghouse. |
1/27/2021 | Electronic Data Interchange |
|
Trading Partner Agreement (Fillable)
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. |
1/27/2021 | Electronic Data Interchange |
|
Electronic Funds Transfer Enrollment Request (Fillable)
Use this form to enroll in electronic funds transfer in order to streamline the reimbursement process. |
1/27/2021 | Administrative and Billing |
|
Trading Partner Registration (Non-fillable)
This is registration that a provider must complete in order to electronically transact with BCBSNE. Not required for providers using a clearinghouse. |
1/27/2021 | Electronic Data Interchange |
|
Trading Partner Agreement (Non-fillable)
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. |
1/27/2021 | Electronic Data Interchange |
|
Electronic Funds Transfer Enrollment Request (Non-fillable)
Use this form to enroll in electronic funds transfer in order to streamline the reimbursement process. |
1/27/2021 | Administrative and Billing |
|
Check Return Form (Fillable)
Use this form to return an overpayment not already requested by BCBSNE. This version has fillable fields to complete but may not work with all versions of Adobe Reader or Acrobat. |
11/23/2020 | Administrative and Billing |
|
W-9 Form (Fillable)
If submitting as part of a credentialing request, please send to CredentialingRequests@NebraskaBlue.com, all other forms can be sent to HealthNetworkRequests@NebraskaBlue.com |
3/4/2021 | Health Network Administration |
|
Reconsideration Request Form (Fillable)
Use this form to submit reconsideration. |
3/9/2021 | Claims and Benefits |
|
Electronic Remittance Advice Form (Fillable)
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. |
3/18/2021 | Electronic Data Interchange |
|
Electronic Remittance Advice Form (Non-fillable)
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. |
3/18/2021 | Electronic Data Interchange |
|
Timely Filing Override Request
|
3/29/2021 | Administrative and Billing |
|
LB997 - Out of Network Emergency Medical Care Act Reimbursement Dispute Request
|
4/12/2021 | Administrative and Billing |