Claims Edits Information

The goal of Blue Cross and Blue Shield of Nebraska's (BCBSNE) medical claims review software is to improve the efficiency and accuracy of our claims processing system.  

The claims review software uses nationally accepted and sourced guidelines, including Current Procedural Terminology (CPT) regulations as documented by the American Medical Association (AMA), Correct Coding Initiatives (CCI) and Post-Operative Period Guidelines as outlined by the Centers for Medicare and Medicaid Services (CMS).

Program components include: 


  • National CCI (as defined by CMS)

    • Comprehensive
    • Mutually Exclusive
    • New Visit Principles
    • Add-On Principles 
    • Medically Unlikely Principles 
    • Multiple Unit Principles
    • Global Surgery 

    Based on the frequency of guideline source updates, these edits are subject to change and additional guidelines will be added without prior notice.  

    With the implementation of this program, claims submitted with inappropriate coding will be returned or denied.  Providers will be notified via a return letter or remittance advice, which will include a reason code for the claim return or denial.  Any returned claims must be corrected prior to resubmission. 

    To help you understand the codes, we encourage you to refer to the following resources:

    Medically Unlikely Edits (MUE) – Provides access to frequently asked questions on MUEs, along with updated MUE information.

    National Correct Coding Initiative (NCCI) Edits – Provides guidance on the NCCI policy manual for Medicare Services.

    The National Correct Coding Initiative (NCCI) – FAQs regarding NCCI edits for Iowa, Kansas, Missouri and Nebraska providers. 

    To check for the most current status on recently submitted claims, go to NaviNet

    For escalated claims questions, please call (800) 635-0579.


    Note: When claims are returned or denied due to the claims edits, submitting an appeal or a reconsideration is not necessary. Please resubmit the corrected claim electronically. Please note the policy below.

    Requirement for Electronic Claim Submitters

    Electronic claim submitters MUST file their corrected (replacement) claims electronically.  Corrected claims submitted on paper by a provider who has electronic claim filing capabilities will be returned with instructions to submit the corrected claim electronically.


    If your corrected claim will include attachments, your corrected paper claim must be filed to Blue Cross and Blue Shield of Nebraska, attached to a Reconsideration Request Form, as you have done in the past.


    If you have any questions regarding how to submit a replacement claim electronically, please refer to the HIPAA ANSI X12N 837P or HIPAA ANSI X12N837I implementation guide for detailed instructions.





    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.

    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).


    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.