In-Network Provider Policies and Procedures

Our in-network policies and procedures manuals provide important information of the following BCBSNE provider types:

  • Physician and Health Care Professionals
  • Facilities
  • Psychiatric
  • Dental providers when filing medical claims*

*Dental provider’s policies (when filing a dental claim) are located on the Dental Policies page.


 General Policies and Procedures Manual

(pdf, 1,424 KB; Updated 1/25/19)

  • Provider/Member Responsibilities
  • BlueCard Program
  • FEP (Federal Employee Health Benefits Program)
  • Guidelines on claims submissions, payments and refunds
  • BCBSNE Quality Management Program
  • Network Requirements/Rights
    • How to become an in-network provider
    • Network Termination
    • Appeal and Reinstatement
    • Administrative disputes
    • Provider Corrective Actions
  • Member benefit appeal process
  • Special Investigations Unit
  • Non-covered services
  • How to contact us


 Billing and Reimbursement Manual

(pdf, 1,212 KB; Updated 1/25/19)
Includes billing and reimbursement requirements for:

  • FEP Program
  • Home Medical Equipment
  • Home infusion
  • Home health
  • Hospice
  • Mental Health
  • How to contact us



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


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. 


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.


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.)


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


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.


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.


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).


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.