Forms for Providers

Looking for Pharmacy forms? Visit our Pharmacy Management page.

Radiology Preauthorization Program through Clear Coverage

BCBSNE performs 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)

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

Check Return (pdf) updated 11/06/2001

Use this form to return an overpayment not already requested by BCBSNE.

Check Tracer (pdf) updated 11/15/2015

Required for missing checks only.


Claims

Appeal Reconsideration Request (pdf) updated 09/15/2015

Use this form to submit a corrected claim or appeal a claim determination.


Clinical Measure Forms

Obstetrical Needs Assessment (pdf) updated 12/08/2015

Use this form to let us know about any gaps in care you may have closed.


Coordination of Benefits (COB)

Universal COB Questionnaire (pdf)

Use this form to report other insurance information. It must be completed by the policy holder, but may be submitted by a member or provider.
(this form is currently not interactive)


Electronic Data Interchange (EDI)

Electronic Funds Transfer Enrollment or Virtual Card Payment Request (pdf)

Use this form to register for electronic funds transfer or to receive reimbursement via our virtual card payment process.

Electronic Remittance Advice Form (pdf) *

Use this form 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 (pdf) * updated 04/15/2004

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 (pdf) *

This is registration that a provider must complete in order to electronically transact with BCBSNE. Not required for providers using a clearinghouse.


Health Network Administration

Change of Address (pdf) *

Providers may use this form to change an address with BCBSNE. If you are participating in a PHO, contact your PHO representative to report your changes. This form is for use by Nebraska providers only.

Extend-Transfer Existing Agreements (pdf) * updated 06/05/2017

Use this form 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. This form is for use by Nebraska providers only.

NPI Notification (pdf) *

Use this form to report your Individual or Organizational NPI number to BCBSNE. This form is for use by Nebraska providers only.

Privacy Waiver Form (pdf) updated 12/10/2013

Use this form when a member requests that a provider restrict the disclosure of PHI to BCBSNE.

Provisional Provider Form (pdf) *

This form is for use 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. This form is for use by Nebraska providers only.


Utilization Management

Note: Please submit requests using the appropriate ICD-10 codes.

Behavioral Health Outpatient Form (pdf) updated 03/01/2016

This form is required to be submitted for more than 90 visits.

Preauthorization Request (pdf) updated 09/14/2017

Submit this form with medical rationale for preauthorization review of a medical/surgical service.

Psych/Neuropsych Evaluation Request (pdf) updated 03/01/2016

Psych/Neuropsych testing in excess of four hours must be preauthorized using this form.

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.