Forms for Providers

Looking for Pharmacy forms? Visit our  Pharmacy Management page.

Radiology Preauthorization Program through Clear Coverage

Effective Oct. 1, 2016, BCBSNE will perform in-house radiology reviews for the following services using Clear Coverage, a web-based preauthorization tool.

  • Computed Tomography (CT/CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)

Beginning Oct. 1, 2016, if the services listed above are not preauthorized, claims may be denied and you may be responsible for payment of the charges.

Please note: Plain radiology films, imaging studies performed in conjunction with emergency room services and inpatient hospitalizations are excluded from this requirement.

Visit http://medicalpolicy.nebraskablue.com/clearcoverage to create your Clear Coverage user account today. 

Accounting

Form Purpose 
Check Return Use to return an overpayment not already requested by BCBSNE.
Check Tracer  Required for missing checks only.

Claims

Form Purpose
Appeal Reconsideration Request Use to submit a corrected claim or appeal a claim determination.

Coordination of Benefits (COB)

Form Purpose
Universal COB Questionnaire



(this form is currently not interactive)
Used to report other insurance information. Must be completed by policy holder, but may be submitted by member or provider.

Electronic Data Interchange (EDI)

Form Purpose
Electronic Funds Transfer Enrollment or Virtual Card Payment Request Use this form to register for electronic funds transfer or to receive reimbursement via our virtual card payment process.
Electronic Remittance Advice Form*

Used to enroll in our Electronic Remittance Advice (ERA) service. This form is also used to update your ERA information already on-file with BCBSNE.

 

Trading Partner Agreement*

This is a HIPAA-required business associate agreement between BCBSNE and its trading partners; this agreement is a legally binding contract. Not required for providers using a clearinghouse.

 

Trading Partner Registration* Registration that a provider must complete in order to electronically transact with BCBSNE.Not required for providers using a clearinghouse.

Health Network Administration

Form Purpose 
Change of Address* Used when a provider needs to change their address with BCBSNE. If you are participating in a PHO, contact your PHO representative to report your changes. For use by Nebraska providers only.
Extend-Transfer Existing Agreements* Used to extend your network status to a new or additional location. If you are participating in a PHO, contact your PHO representative to report your changes. For use by Nebraska providers only.
NPI Notification* Used to report your Individual or Organizational NPI number to BCBSNE. For use by Nebraska providers only.
Privacy Waiver Form Used when a member requests that a provider restrict the disclosure of PHI to BCBSNE.
Provisional Provider Form* Used by provisionally-licensed behavioral health providers to report their practitioner information and their supervising practitioner's information. This form must be completed and processed before claims can be submitted. For use by Nebraska providers only.

Utilization Management

Note: Starting Oct. 1, 2015, please submit requests using the appropriate ICD-10 codes.

Form Purpose
Behavioral Health Outpatient Form This form is required to be submitted for more than 90 visits.
Preauthorization Request Use to submit with medical rationale for preauthorization review of a medical/surgical service.
Interqual SmartSheet  - Total Joint Replacement, Hip Pre-service review form for the Knees, Hips, and Back Procedure Review Pilot Program for employees of BCBSNE (YED and NEQ alpha prefixes), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.
Interqual SmartSheet - Total Joint Replacement, Knee Pre-service review form for the Knees, Hips, and Back Procedure Review Pilot Program for employees of BCBSNE (YED and NEQ alpha prefixes), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.
Interqual SmartSheet - Angioplasty and Stent Carotid Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016
Interqual SmartSheet - Endometrial Ablation Pre-service review form for all BCBSNE members.
Interqual SmartSheets - Hysterectomy Click here to access the SmartSheets for the hysterectomy pre-service review program for all BCBSNE members.
Interqual SmartSheets - Kyphoplasty Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Interqual SmartSheets - Left Ventricular Assist Device (LVAD) Insertion Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Interqual SmartSheets - Mastectomy Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Interqual SmartSheets - Obesity Surgery Click here to access the SmartSheets for the obesity surgery pre-service review program for all BCBSNE members, effective Jan. 1, 2016.
Interqual SmartSheets - Pacemaker Insertion Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Interqual SmartSheets - Radiofrequency Ablation Click here to access the pre-service reor all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Interqual SmartSheets - Reduction Mammoplasty  Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2017.
Interqual SmartSheets - Sinus Surgery Click here to access the SmartSheets for the sinus surgery pre-service review program for all BCBSNE members.
Interqual SmartSheets - Sleep Studies Click here to access the SmartSheets for the sleep studies pre-service review program for all BCBSNE members, effective Jan. 1, 2016.
Interqual SmartSheets - Stimulation Surgery Click here to access the SmartSheets for the stimulation surgery pre-service review program for all BCBSNE members, effective Jan. 1, 2016.
Interqual SmartSheets - Varicose Veins Click here to access the SmartSheets for the stimulation surgery pre-service review program for all BCBSNE members, effective Jan. 1, 2016.
Interqual SmartSheets - Vertebroplasty Pre-service review form for all BCBSNE members for the prior authorization program, effective Jan. 1, 2016.
Psych/Neuropsych Evaluation Request  Psych/Neuropsych testing in excess of four hours must be preauthorized using this form.

* Electronic forms require Internet Explorer web browser and Adobe Acrobat PDF software. Mac users may download the form to their desktop and complete using Adobe Acrobat.

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.