Network Termination – Second Level of Appeal

Policy Number: GP-X-068

Last Updated: July 17, 2022  

A second-level appeal is available only to participating providers whose participation or payable status in the plan networks is being terminated for cause.

Note: Providers that leave a delegated credentialing arrangement will be treated as new applicants and therefore will only be eligible to receive one level of appeal if network participation is denied.  

The second-level appeal request must be made in writing and submitted to Blue Cross and Blue Shield of Nebraska (BCBSNE) within 30 business days of the date of the Hearing Committee’s decision letter. BCBSNE will furnish written notice of the date and time of the hearing within 30 business days of receiving the appeal request. The hearing will be held at BCBSNE’s offices in Omaha, Nebraska, as soon as reasonable arrangements can be made. The hearing will be conducted not more than 45 business days from the date the appeal request was received unless the provider or Hearing Committee is unable to participate within that timeframe. In this case, the hearing will be held within 90 business days of the request unless otherwise agreed upon by both parties.  

The second-level Hearing Committee members will consist of one person selected by each party to the appeal and one individual mutually agreeable to both parties. At least one member of the committee shall be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute. The first-level Hearing Committee panel members may not participate in the second-level appeal hearing. The Chief Medical Officer (CMO) or designee will serve as chairperson for the second level hearing but shall not vote in the decision of the Hearing Committee. Each party pays costs for the person it selected and shares the costs of the third. Costs are not recoverable.  

If the parties cannot mutually agree on the third Hearing Committee member, the two Hearing Committee members (selected by each party to the appeal) will choose the third Hearing Committee Member. The parties may stipulate that the committee members select a candidate that practices in the same specialty as the participating provider.  

Minutes of the hearing are recorded and made available to the provider upon written request.  

Within 15 business days of the final adjournment of the hearing, the Hearing Committee shall decide. A majority vote is required to overturn the original adverse recommendation.  

Note: The provider’s right to a hearing will be forfeited if the provider fails, without good cause, to appear at the scheduled hearing of either the first- or second-level appeal or if the provider fails to participate in good faith in the appeal and fair hearing process. In such cases, the original adverse recommendation will stand as the final decision.