Toddler recovers in hospital pediatric intensive care unit and plays with a toy yellow bus

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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
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
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
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
LB997 - Out of Network Emergency Medical Care Act Reimbursement Dispute Request
4/20/2021 Administrative and Billing
Electronic Funds Transfer Enrollment Request (Non-fillable)
Use this form to enroll in electronic funds transfer in order to streamline the reimbursement process. 		11/9/2021 Administrative and Billing
Electronic Funds Transfer Enrollment Request (Fillable)
Use this form to enroll in electronic funds transfer in order to streamline the reimbursement process. 		11/9/2021 Administrative and Billing
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
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. 		12/8/2020 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. 		12/8/2020 Electronic Data Interchange
Appeal Request Form (Non-fillable)
Use this form to appeal a claim determination. 		12/17/2019 Claims and Benefits
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 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
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
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
Psychological/Neuropsychological Evaluation Request
Psych/Neuropsych testing in excess of four hours must be preauthorized using this form. 		3/1/2016 Utilization Management
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. 		5/4/2022 Health Network Administration
Appeal Request Form (Fillable)
Use this form to appeal a claim determination. 		12/17/2019 Claims and Benefits
Extend-Transfer Existing Agreements (Non- fillable)
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. 		5/4/2022 Health Network Administration
Extend-Transfer Existing Agreements (Fillable)
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. 		5/4/2022 Health Network Administration
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. 		5/4/2022 Health Network Administration
Check Replacement Form (Fillable)
Required for missing checks only. 		5/24/2022 Administrative and Billing
Check Replacement Form (Non-fillable)
Required for missing checks only. 		5/24/2022 Administrative and Billing
Change of Address Form (Non-fillable)
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. 		6/14/2022 Administrative and Billing
Change of Address Form (Fillable)
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. 		6/14/2022 Administrative and Billing
Institutional/Facility Recredentialing Application (Fillable)
Use this form for Institutional Facility recredentialing. 		8/8/2022 Administrative and Billing
Timely Filing Override Request (Non-fillable)
Use this form to request an override of a claim denied for timely filing. 		1/5/2023 Administrative and Billing
Timely Filing Override Request (Fillable)
Use this form to request an override of a claim denied for timely filing. 		1/5/2023 Administrative and Billing
Reconsideration Request Form (Fillable)
Use this form to submit reconsideration. 		1/23/2023 Claims and Benefits
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