Find a Form
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
- 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.
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.
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:
- Right click on PDF name
- Select “Save target as” or “Save link as” to save it to your device
- 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 |
|
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 |
|
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 |
|
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 |
|
CMS 1500
A blank copy of the standard paper claim form to bill Medicare fee-for-service providers. The electronicversion is the 837P. |
3/8/2019 | Policy and Procedure Documents |
|
Coordination of Benefits Spanish (Non-fillable)
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. |
11/21/2023 | Administrative and Billing |
|
Coordination of Benefits Spanish (Fillable)
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. |
11/21/2023 | Administrative and Billing |
|
Coordination of Benefits (Non-fillable)
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. |
11/21/2023 | Administrative and Billing |
|
Coordination of Benefits (Fillable)
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. |
11/21/2023 | Administrative and Billing |
|
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 |
|
Outpatient Treatment Plan
This form is required to be submitted for more than 90 visits. |
12/26/2023 | Utilization Management |
|
Preauthorization Request (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 |
|
Check Replacement Form (Fillable)
Required for missing checks only. |
3/15/2024 | Administrative and Billing |
|
Check Replacement Form (Non-fillable)
Required for missing checks only. |
3/15/2024 | Administrative and Billing |
|
Credentialing - Professional (Non-fillable)
Use this form for professional credentialing. |
4/4/2024 | Administrative and Billing |
|
Credentialing - Professional (Fillable)
Use this form for professional credentialing. |
4/4/2024 | Administrative and Billing |
|
Provisional Provider Form
|
2/5/2025 | Health Network Administration |
|
Network Oversight Form
|
3/6/2025 | Administrative and Billing |
|
Credentialing/Recredentialing - Institutional/Facility (Non-fillable)
Use this form for Institutional Facility recredentialing. |
10/14/2024 | Administrative and Billing |
|
Credentialing/Recredentialing - Institutional/Facility (Fillable)
Use this form for Institutional Facility recredentialing. |
10/14/2024 | Administrative and Billing |
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