Network Termination – First Level of Appeal

The notification of declined participation, non-payable status or termination will contain the applicable reason(s) for the adverse action, the grounds upon which the adverse action is based, and any other relevant subject matter that was considered. The notification will also inform the provider they have 30 business days from the date of the notification to submit a written appeal request when the reason for the declined participation, non-payable status or termination is appealable.  

Within 60 calendar days of receiving an appeal request, Blue Cross and Blue Shield of Nebraska (BCBSNE) will furnish the provider with written notice of the date and time of the hearing. The hearing will be held at BCBSNE’s offices in Omaha, Nebraska, or virtual as soon as reasonable arrangements can be made. The hearing will be conducted not more than 75 calendar days from the date the appeal request was received unless the provider or Hearing Committee is unable to participate within that time frame. In that case, the hearing will be held within 120 calendar days of the request. 

The Chief Medical Officer (CMO) or designee shall determine the Hearing Committee members. At least one member of the hearing panel includes an actively practicing clinical peer of the practitioner, who practices in the same or similar specialty, and who is not otherwise involved in network management.

The CMO or designee may request the appearance of up to two individuals at the hearing to answer questions and/or to make a statement on BCBSNE’s behalf. The individuals shall not vote in the decision of the Hearing Committee.  

The provider may have up to two people attend the hearing on the provider’s behalf to answer questions and/or to make a statement on the provider’s behalf.  

Each person appearing at the hearing is limited to 15 minutes of speaking time. Both the provider and the Hearing Committee have the right to question the individuals appearing on behalf of either side.  

The CMO or designee shall serve as chairperson for the hearing but shall not vote in the decision of the Hearing Committee. The chairperson shall preside over the hearing and determine the order of procedure to ensure all participants in the hearing have a reasonable opportunity to present relevant verbal and documentary evidence, and to maintain decorum. Upon conclusion of the presentation of verbal and written evidence, the hearing shall be closed. The provider may submit a written statement at the close of the hearing before deliberations.  
 
Minutes of the hearing will be recorded and made available to the provider upon written request.  

Hearings are not open to the public and are not subject to formal rules of evidence. Either party may present material evidence or testimony as may be necessary to resolve the dispute. The applicable Nebraska statute does not provide for immunity of the proceedings.  
 
Within 60 calendar days of the final adjournment of the hearing, the Hearing Committee shall decide. A majority vote is required to overturn the original adverse recommendation.  The VP of Provider Services or designee shall promptly notify the provider by certified mail of the decision of the Hearing Committee and the action to be taken as a result of such decision.