Network Termination – Non-Appealable Decisions

Policy Number: GP-X-069

Last Updated: July 14, 2022 

Non-appealable issues include, but are not limited to:

  • Contracting requirements for networks:
    • Lack of privileges at a contracting facility  
    • Lack of covering contracting practitioners  
    • Not participating in the organized delivery system or group model  
    • No geographic need  
    • No need for specialty  
    • Change in practice affiliation or location  
  • If the provider’s license to practice is currently revoked, terminated or suspended 
  • If the practitioner’s Federal Drug Enforcement Administration or Centers for Disease Control and Prevention issued number is currently revoked or suspended (if it is required for practitioner’s profession) 
  • If the provider is convicted of a felony or is expelled or suspended from Medicare or Medicaid programs (Title XVIII or XIX of the Social Security Act) 
  • If the provider’s professional liability insurance coverage does not meet the coverage requirements of Blue Cross and Blue Shield of Nebraska  
  • Any material misrepresentation made by the provider during network participation 
  • Primary office location is not in Nebraska or contiguous county 
  • Lack of office facility, cessation of business or insolvency of the provider