Payment Disputes for Contracted and Non-contracted Providers

(not related to claim denials or retrospective audits)  
Provider payment disputes include any decisions where there is a dispute that the payment amount made by the Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage plan to providers is less than the payment amount that would have been paid under the Medicare fee schedule.  

If you believe that the payment amount you received for a service is less than the amount paid by Medicare, you have the right to dispute the payment amount by following our payment dispute process.  

First Level Appeals  
Provide appropriate documentation to support your payment dispute, such as a remittance advice from a Medicare carrier. Claims must be disputed within 120 days from the date payment is initially received.  

We will review your dispute and respond to you within 60 days from the time we receive notice of your dispute. If we agree with your position, then we will pay you the correct amount with any interest that is due. We will inform you in writing if your payment dispute is denied.  

To file a payment dispute with BCBSNE, submit your dispute in writing or by telephone as shown below:

Second Level Appeals  

After completing the first level payment dispute process as described above, if you still believe that we have reached an incorrect decision regarding your payment dispute, you may file a request for a secondary review of this determination within 60 days of receiving written notice of our first level decision.  

We will review your dispute and respond within 60 days of the date on which we received your request for a secondary review. Please provide appropriate documentation to support your payment dispute and a copy of the first level decision letter. Decisions from this secondary review will be final and binding.  

You may file a request for a secondary review of this determination in writing to: 

Be sure to include the following information with your request for a payment dispute: 

• Provider or supplier contact information including name and address
• Pricing information, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code where services were rendered and physician specialty 
• Reason for dispute -- a description of the specific issue 
• Copy of the provider’s submitted claim with disputed portion identified 
• Copy of the plan’s original pricing determination 
• Documentation and any correspondence that supports your position that the plan’s reimbursement was incorrect (including interim rate letters when appropriate) 
• Appointment of provider or supplier representative authorization statement, if applicable 
• Name and signature of the provider or provider’s representative