Complaint Investigation and Process

Policy Number: GP-X-074

Last Updated: Sept. 12, 2022 

The Quality Improvement (QI) department tracks trends, analyzes, investigates and facilitates resolution of complaints from members, providers, employer groups and brokers as well as internal sources. Investigation of these potential issues may involve: 

  • Obtaining medical record documentation related to the concern, 
  • Contacting the provider’s office directly to discuss service or access issues, and/or 
  • Soliciting additional information directly from the practitioner to supplement medical record findings.  

Complaints related to the quality of care rendered to a member are reviewed by the Blue Cross and Blue Shield of Nebraska (BCBSNE) medical director or designee to determine if a quality-of-care issue exists and its severity. Significant quality-of-care issues are presented for peer review at the BCBSNE Quality Management Committee comprised of practicing network physicians not employed by BCBSNE. Recommendations for further action, if appropriate, are determined by the committee. The QI complaint process enables tracking and trending of issues of concern and serves as a valuable tool for maintaining high quality provider networks, as well as improving processes and services our members expect from their health plan.