Appeals
An appeal asks BCBSNE to review a pre- or post-service denial. Examples include medical necessity, policy, or investigational determinations.
Processes and timelines depend on the member’s contract and laws. Include any new medical information to avoid delays.
Nebraska providers appealing for non-Nebraska members should follow the steps below.
Preservice and post service reviews include, but are not limited to:
- Medical necessity
- Investigative
- Cosmetic
- Contract exclusions
- No preauthorization obtained
- Pre-existing
- Medical emergency
- Medical vs. dental
- In-network vs. out-of-network
Some medical necessity and investigative appeal reviews are sent to outside organizations, called Independent Review Organizations (IRO). An IRO will conduct an independent review of the adverse determination for eligible appeals.
For out-of-network providers, the forms are available on our Provider Forms page.
Please refer to the Medicare Advantage (MA) BCBSNE Provider Procedure, Contracted Provider Appeals, regarding MA appeals requests.
For additional information regarding BCBSNE MA provider procedures, refer to the BCBSNE Provider Procedures page.