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Below are various printable forms to help with your day-to-day patient care and administration. Find Medicare Advantage Forms »

Effective 5/15/23, all forms used to update demographic and practice data will only be available only through NaviNet via the Administrative Updates/Secure Forms. This includes the forms to update EFT information. You can access the forms under the Resources section.

  • NPI Notification
  • Electronic Funds Transfer Enrollment Request 
  • Provisional Provider Form 
  • Extend-Transfer Existing Agreements 
  • Change of Address Form 

Effective 7/18/23, all Appeal, Reconsideration and Timely Filing Override Requests should be submitted using NaviNet's new Claim Appeal function. This will allow you to track your submissions and their status. See the following help guide or watch the video for assistance with this process.

  Help Guide

If you do not have a NaviNet account, please visit https://connect.NaviNet.net/enroll to begin the registration process. All participating BCBSNE health care and dental providers can enroll for access. 

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TIP: If you are unable to see the PDFs, please read tips from Adobe Reader or follow the steps below to download them.

To download the forms:

  1. Right click on PDF name
  2. Select “Save target as” or “Save link as” to save it to your device
  3. Open the file in this saved location.
Type Title Date Category
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
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
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
Check Replacement Form (Fillable)
Required for missing checks only. 		6/12/2023 Administrative and Billing
LB997 - Out of Network Emergency Medical Care Act Reimbursement Dispute Request
4/20/2021 Administrative and Billing
Timely Filing Override Request (Non-fillable)
Use this form to request an override of a claim denied for timely filing. 		5/1/2023 Administrative and Billing
Check Replacement Form (Non-fillable)
Required for missing checks only. 		6/12/2023 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
Appeal Request Form (Fillable)
Use this form to appeal a claim determination. 		4/26/2013 Claims and Benefits
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
Timely Filing Override Request (Fillable)
Use this form to request an override of a claim denied for timely filing. 		5/1/2023 Administrative and Billing
Appeal Request Form (Non-fillable)
Use this form to appeal a claim determination. 		4/26/2023 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
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
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. 		12/20/2020 Electronic Data Interchange
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. 		12/8/2020 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. 		12/20/2020 Electronic Data Interchange
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. 		4/24/2023 Electronic Data Interchange
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. 		12/8/2020 Electronic Data Interchange
Reconsideration Request Form (Fillable)
Use this form to submit reconsideration. 		8/16/2023 Claims and Benefits
Preauthorization Request (Non-fillable)
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. 		10/12/2021 Preauthorization
Credentialing/Recredentialing - Institutional/Facility (Non-fillable)
Use this form for Institutional Facility recredentialing. 		9/5/2023 Administrative and Billing
Credentialing/Recredentialing - Institutional/Facility (Fillable)
Use this form for Institutional Facility recredentialing. 		9/5/2023 Administrative and Billing
Credentialing - Professional (Fillable)
Use this form for professional credentialing. 		6/12/2023 Administrative and Billing
Credentialing - Provisional Provider (Fillable)
Use this form for provisional provider credentialing. 		5/4/2022 Administrative and Billing
Credentialing - Professional (Non-fillable)
Use this form for professional credentialing. 		6/12/2023 Administrative and Billing
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