Member Benefit Appeals

All Blue Cross and Blue Shield of Nebraska (BCBSNE) contracts adhere to the applicable state and/or federal guidelines governing appeals. Appeals are performed by nurses and/or physicians who were not previously involved in the review or appeal process. When requesting an appeal, it is important to submit all relevant information to assist in the review. 

Expedited Appeal

BCBSNE offers expedited appeals to the attending/ordering provider, patient/enrollee and facility when services are not certified, and the situation meets the requirements for an expedited appeal. 

The appeal is expedited if it meets the criteria below. All other appeals are standard appeals.

Criteria for Expedited Appeal

An appeal is expedited if it meets the following criteria. All other appeals are standard.  

• Urgent Care Claim: Any claim for medical care or treatment where the standard time periods for non-urgent care determinations:  
  • Could seriously jeopardize the claimant's life or health or their ability to regain maximum function.
  • Would subject the claimant to severe pain that cannot be adequately managed without the care or treatment in question, as determined by a physician with knowledge of the claimant's medical condition.

First Level of Appeal 

The first level of appeal may be expedited or non-expedited and should be submitted via the appeal form in NaviNet^®. For most groups covered by BCBSNE, the time frame for requesting a first-level appeal is six months from the initial denial of benefits. The following information will assist the attending provider in requesting an appeal. Providers can submit a denied claim appeal online via NaviNet.

BCBSNE cannot delay or postpone an appeal decision if additional information is requested but not received. For expedited first-level appeals, a determination will be made within 72 hours of the request. Appeals should be submitted via NaviNet. 

Appeals can be submitted in writing using the appeal form or verbally by calling 402-982-8314 or toll-free 877-448-3339 using the appeal form. Appeal forms can be found at NebraskaBlue.com/Providers/Find-a-form. For non-expedited appeals, a decision will be made within 15 business days or 30 calendar days (depending on the group's contract) from receipt of the appeal request.

The attending provider will be notified of the appeal determination within 72 hours for expedited appeals. Written notification will be sent for both expedited and non-expedited appeal determinations. 

Second Level of Appeal (if applicable)  

A second level of appeal is available when the first level of appeal results in a denial of benefits. The denial letter will provide information on how to request a second-level appeal, if applicable.

If the second-level appeal results in a denial of benefits, the appeal process at BCBSNE is exhausted, and no further appeals are available.  

Denial Upheld on Appeal  

When a denial is upheld on appeal, the attending provider has the right to request in writing: 

• A copy of the rule, guideline, protocol or other similar criteria that was relied upon in making the decision (if applicable); and 
• An explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances (if the denial is based on medical necessity or experimental treatment or similar exclusion or limit).  

 

 

_{NaviNet is a healthcare provider portal providing services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross Blue Shield Association.}