MA Contracted Provider Appeals

Providers Appealing Care Management Decisions 
Par providers and practitioners who provide services for Medicare Advantage members have the right to appeal any denial decision made by Blue Cross and Blue Shield of Nebraska (BCBSNE) and is governed by our contract with the provider. The provider appeals process for Medicare Advantage members and non par providers, however, is governed by Medicare regulations. Provider claims appeals should follow the outlined below. For all other appeals, please refer to the grievance and appeal provider procedure. 

Appeals of Claim Denials and/or Medical Necessity Denials 
(Not related to retrospective audits) 
Contracted providers with BCBSNE Medicare Advantage plans have the right to appeal denied claims, including those related to medical necessity and appropriateness. 

Appeal Limits for Contracted Providers 

• Contracted (network or participating) providers may submit no more than two (2) appeals for any single claim. 
• The first appeal must be submitted within 65 days of the initial denial notice in the Remittance advice/835. 
• If the provider disagrees with the outcome, a second and final appeal may be submitted within 65 days of the first decision. 
• Decisions made after the second appeal are final and binding. No further appeals will be accepted. 

Claims Submitted Following Prior Authorization Denial

• Services rendered by a provider following a denial of prior authorization are not eligible for reconsideration or review.    

Claims Submitted without Required Authorization 

• As a participating Blue Cross Blue Shield of Nebraska provider, it is the provider’s responsibility to be aware of and obtain prior authorization for services that require it. In cases where prior authorization was not obtained, we will allow a one-time submission of all relevant medical records to support a medical necessity review. Only one reconsideration will be permitted for such claims. 

Required Documentation for Medical Necessity Appeals 
To ensure timely and accurate review, providers must include the following with their appeal submission:

• Provider or supplier contact information (name and address)
• Pricing details, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code of service, and physician specialty 
• A clear description of the issue in dispute 
• A copy of the submitted claim with the disputed portion identified 
• Supporting documentation and correspondence that demonstrate why the denial was incorrect (e.g., clinical rationale, Local/National Coverage Determination references) 
• Authorization statement for provider or supplier representative, if applicable 
• Name and signature of the provider or provider’s representative 
• A surgical bill sheet will not be enough documentation to prove medical necessity. 

Appeals Involving LCD/NCD Denials 
If a claim denial is based on a Local Coverage Determination (LCD) or National Coverage Determination (NCD), contracted providers may include relevant evidence and references in their appeal submission to support medical necessity. This includes:

• Citing applicable LCDs or NCDs that support the service or item provided 
• Providing clinical documentation that demonstrates how the service meets the coverage criteria outlined in the LCD/NCD 
• Submitting peer-reviewed literature or clinical guidelines, if applicable 

Review your claim to make sure relevant diagnosis codes are present and proper linkage (pointers) between procedure codes and diagnosis codes are present before submitting the appeal  

BCBSNE will review the appeal in accordance with Medicare guidelines and applicable coverage determinations.    

Submission Instructions

Nebraska Providers:

Mail to: 
Blue Cross and Blue Shield of Nebraska 
Attn: Appeals Department 
P.O. Box 3248 
Omaha, NE 68180-0001 
Fax: 210-579-6930 
Phone: 888-505-2022 

Non-Nebraska Providers: 
Submit appeals through your local Blue plan.