Prior Authorization

At Blue Cross and Blue Shield of Nebraska (BCBSNE), member safety is a top concern. To ensure the necessity and appropriateness of procedures and services for our members, a prior authorization program is in place, which includes pre-service reviews.

The following services require pre-service review:
  • Computed Tomography (CT/ CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)

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

If the service is not pre-authorized, THE CLAIM MAY BE DENIED AND YOU MAY BE RESPONSIBLE FOR PAYMENT OF THE CHARGES.

Members Residing Within Nebraska

If you reside within Nebraska, contracting providers with BCBSNE are responsible for obtaining pre-service reviews for the services listed above. Nebraska-based providers have been notified about this change. If a contracting provider fails to obtain a pre-service review, he or she will be held responsible for any charges related to services performed.

Members Residing Outside of Nebraska

If you reside outside of Nebraska, you may see providers who practice outside of the state. It is important to note that BCBSNE does not have contractual agreements with out-of-state providers, and these providers may not be aware of the prior authorization and pre-service programs required for your health plan.

It is ultimately your responsibility to see that a pre-service review takes place when required. If your provider does not submit a pre-service request for the services listed, the claims for those services will be denied and may be considered your liability.

To avoid possible denial and financial responsibility for the charges if a pre-service review is not done, please familiarize yourself with the services noted, and request that your provider submit a pre-service review if needed, by visiting medicalpolicy.nebraskablue.com.

Also note that if a pre-service review is submitted, but not approved, and the service is provided, you may be held liable for charges for services determined to be not medically necessary.

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.