Subrogation

General
Policy Number: GP-X-011

Last Updated: Jan. 31, 2022 

The health plans underwritten and/or administered by Blue Cross and Blue Shield of Nebraska (BCBSNE) have a contractual right to recover amounts paid because of an injury/illness caused by a third party. This priority line of the health plan on proceeds paid by a third party applies whether the member has been fully compensated. The health plans also may have a contractual right of reimbursement from other proceeds to the extent benefits were also paid under the health plan for the same illness or injury.  

Before sending in an accident claim  

As an in-network provider, you have agreed to file all claims to BCBSNE for any covered benefit provided to members and to accept BCBSNE’s allowance as payment in full. All claims should be submitted to BCBSNE, even if the member request they only be filed to third-party insurance.  

If a covered benefit involves claims that are a result of an accident or illness caused by a third party, you must file a claim including accident information to BCBSNE. We will provide benefits according to the member’s contract and supply payment to the service provider, pursuant to our agreement with them. If the claim is submitted past the applicable timely filing limit, no payment will be made.  

BCBSNE’s Subrogation department will begin the necessary procedures to recover paid amounts from the covered person or third-party payer, which will not exceed the amount paid in benefits.  

If you are notified of an injury or accident after filing claims to BCBSNE and have not included the accident information on the claim, you should notify our Subrogation department immediately at 402-390-1847 or 800-662-3554.

Subrogation or right of reimbursement term in a member contract  

Subrogation is the right of a person to assume a legal claim of another, or the right of a person who has paid a liability or obligation of another to be indemnified by that person. A right of reimbursement is a contractual term granting one party the right to obtain reimbursement from the other party under certain circumstances. All member contracts with BCBSNE and all health plans administered by BCBSNE contain subrogation and right-of-reimbursement provisions.

How BCBSNE members are affected by subrogation and right of reimbursement  

Member contracts include an obligation to reimburse BCBSNE or the health plan if another party is responsible for payment or if the member is pursuing payment from another source and, in some circumstances, when certain other conditions are met.  

BCBSNE enforces the terms of the contract and pursues recoveries through its Subrogation department. The contractual language in place at the time of the accident will determine the rights and obligations of the parties.

How BCBSNE providers are affected by subrogation and right of reimbursement  

In general, providers are not affected by subrogation or right of reimbursement. In certain circumstances, two insurers may potentially be responsible for payment (usually BCBSNE and the third party/auto insurer). Some BCBSNE member contracts have Coordination of Benefits (COB) language in them, requiring BCBSNE to coordinate benefits with individual auto insurance carriers.  

In some cases, an insurer other than BCBSNE will make payment directly to the provider. The provider may have received payment from BCBSNE, as well. If you receive a payment from two sources, your BCBSNE provider agreements state that you should return the overpayment to BCBSNE, even if the payment received from the third party is less than the BCBSNE payment.  

In all cases, BCBSNE will follow the member contract when processing claims and payments from other sources. In no circumstance should providers send an overpayment to the other insurer or the member without direction from BCBSNE’s Subrogation department.  

With questions, please call the BCBSNE Subrogation department 800-662-3554 or 402-390-1847.