Process to Appeal SIU Sample Audit Findings

Policy Number: GP-X-036

Last Updated: Feb. 28, 2023 

Level-I Appeal Process

The provider is required to submit a written appeal to Blue Cross and Blue Shield of Nebraska (BCBSNE). The appeal must state the specific reason for the dispute. Send the appeal and all required supporting documentation to the following address:

Blue Cross and Blue Shield of Nebraska   
P.O. Box 3248   
Omaha, NE 68180-0001

Required supporting documentation: 

  1. The appeal must be accompanied by new or additional documentation to substantiate the provider’s position. This additional information must meet the following criteria:
    1. The information must be relevant to the disputed issue(s).   
    2. The information must have existed during the dates of service for the record(s) in question.
    3. The information must provide evidence-based supporting documentation.   
  2. If the appeal contests the case review decision of the BCBSNE medical director or other BCBSNE physician consultant, the provider must provide a medical staff member or medical consultant written reply to BCBSNE for review.
  3. Peer-reviewed medical literature and other expert opinion may be included. 
Level-II Appeal Process

Upon communication of the level-I appeal results, the provider has an additional 14 calendar days to submit a written notice of second appeal with additional supporting documentation for SIU staff to review. If the dispute is still unresolved, SIU staff will forward the documentation to the BCBSNE medical director or other BCBSNE physician consultant and, upon the BCBSNE physician or medical director’s decision, the SIU will communicate appeal results back to the provider.

Corrective Action Plans and Repayment Requests 

BCBSNE will initiate a repayment request for identified overpayments. The provider will either be asked to return a check to BCBSNE for the identified repayment amount or allow BCBSNE to take an offset of the overpayment amount. BCBSNE will not initiate repayment requests beyond the time specified in the applicable provider agreement; however, no time limit applies to the initiation of repayment requests based on a reasonable belief of fraud, waste or abuse (FWA) or other misconduct or if required by a state or federal government program.   
When a health care provider fails to comply with BCBSNE billing guidelines or performance standards, the provider may be required to complete a corrective action plan (CAP) to remain in-network.  

The terms of the CAP may require the provider to reimburse BCBSNE for identified overpayments.

Audit and Investigation Outcomes

In addition to the above, when FWA or improper billing are identified during an audit or investigation, BCBSNE reserves the right to take any action necessary to address the identified issues, including but not limited to:

  1. Contact the provider to discuss the findings.
  2. Seek recovery of identified overpayments.
  3. Provide education.
  4. Place the provider under a CAP.
  5. Require periodic self-audits.
  6. Terminate the provider’s BCBSNE participation.
  7. Convert the provider’s status to non-payable.
  8. Refer the investigation findings to law enforcement, medical licensure board, and/or federal, state, or local government agency.
  9. Conduct a full claims audit.
  10. Offset the identified overpayment from future claim payments.   
  11. Require that the provider submit future claims on paper with the medical records supporting the billed item(s) or service(s) prior to adjudication.
  12. File a lawsuit to collect the identified overpayment.   
Reporting FWA 

Concerns regarding FWA can be reported confidentially to BCBSNE by phone or online through the Provider Fraud Inquiry Form at any time. The BCBSNE Fraud Hotline telephone number is 877-632-2583.