Forms for Providers

Looking for Pharmacy forms? Visit our Pharmacy Management page.

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 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.

 

Electronic Funds Transfer Form

Used to enroll in our Electronic Funds Transfer service. This form is also used to update your EFT information already on-file with BCBSNE.

 

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.

 

Request to Participate*

The first step in the Credentialing process for professional (non-facility) providers. For use by providers who are currently not contracted with BCBSNE in any manner.

Note: Provisionally licensed behavioral health providers should not complete the Request to Participate form - please complete the Provisional Provider Form.

Utilization Management

Form Purpose
Behavioral Health Outpatient Form This form is required to be submitted for more than 60 visits.
   

Preauthorization Request

Use to submit with medical rationale for preauthorization review of a medical/surgical service.

Interqual SmartSheet - Fusion, Lumbar Spine

 

Pre-service review form for the Knees, Hips, and Back Procedure Review Pilot Program for BCBSNE (YED alpha prefix), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.

Interqual SmartSheet - Total Joint Replacement, Hip

Pre-service review form for the Knees, Hips, and Back Procedure Review Pilot Program for BCBSNE (YED alpha prefix), 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 BCBSNE (YED alpha prefix), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.

Psych/Neuropsych Evaluation Request 
(this form is currently not interactive)

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.