Reconsideration Requests

Policy Number: GP-X-072

Last Updated: Sept. 8, 2022 

Providers may request reconsideration of the reimbursement level of submitted charges using the Reconsideration Form. Providers are responsible for supplying all information necessary for Blue Cross and Blue Shield of Nebraska (BCBSNE) to evaluate a reconsideration request. 

Reasons for a reconsideration request are:

  • An invoice for pricing review  
  • Worker’s compensation or subrogation  
  • Provider contract pricing (include the relevant fee schedule information being referenced)  
  • Review of medical records for CPT/HCPCS/IDC10 code edits/denials  
  • Other insurance information  
  • Issues regarding modifier submission  

Reconsideration requests are only available if a claim has been processed and the remittance advice (RA) has been issued.  

Please use the following guidelines when submitting a claim for a reconsideration request:  

The correct, most recent version of the reconsideration form must be used. Ensure the form is completed in its entirety, including the BCBSNE claim number and member ID.  

In the Reason section of the form, check the applicable box. In the comments section, provide a concise description of the issue, including the code(s) in question.  

When submitting documentation in support of the reconsideration request, include all relevant documentation, but do not include information that does not pertain to the issue.  

Please note that issues regarding preauthorization, medical necessity denial, investigative denial or no assistant surgeon allowed should be sent as appeals, not as a reconsideration.  

Review instructions on submitting an appeal under the topic of “Member Benefit Appeals.” BCBSNE reserves the right to determine a cost threshold for any reconsiderations requested to be cost-efficient for providers and members. The threshold for reimbursements is $25 based on current costs of claims handling.  

If the denial of is upheld after review, the provider may not submit another reconsideration request unless the necessary documentation was not sent initially. Otherwise, the provider will be required to submit an appeal.  

In all cases, BCBSNE will make a final determination of reimbursement level based upon the criteria detailed above. The covered person is not responsible for payment of disputed charges during the appeal/reconsideration process. The provider may not bill the covered person for any payment under dispute.  
**Please Note**  

Appeals and/or reconsiderations must be received on the correct Appeal OR Reconsideration form. Those received on an INCORRECT form will be returned to the provider.