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
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
Behavioral Health Outpatient Form
This form is required to be submitted for more than 90 visits. 		3/1/2016 Utilization Management
Timely Filing Override Request
9/30/2019 Administrative and Billing
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
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
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
Electronic Funds Transfer Enrollment Request
Use this form to enroll in electronic funds transfer in order to streamline the reimbursement process. 		5/5/2020 Administrative and Billing
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
Reconsideration Request Form (Fillable)
Use this form to submit a corrected claim. 		5/5/2020 Claims and Benefits
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 Replacement Form
Required for missing checks only. 		8/3/2020 Administrative and Billing
LB997 - Out of Network Emergency Medical Care Act Reimbursement Dispute Request
10/8/2020 Administrative and Billing
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
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
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
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