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 that may assist in conducting the appeal.

Expedited Appeal

BCBSNE offers an expedited appeal to the attending/ordering provider, patient/enrollee and facility when a determination is made not to certify services and the situation meets the requirements for an expedited appeal as defined by BCBSNE.

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

A “claim involving urgent care” is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:  

1. Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
2. In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.  

First Level of Appeal 

The first level of appeal may be expedited or non-expedited and should be submitted in writing. Providers are encouraged to use the Appeal form.  

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^®_.

Appeal fillable and non-fillable forms can be found at NebraskaBlue.com/Providers/Find-a-form. These forms can be faxed or mailed to the following:

Fax to 402-548-4684 or 888-492-4944
or
Mail to
Blue Cross and Blue Shield of Nebraska
Appeals Department
P.O. Box 3248 Omaha, NE 68180-0001

The laws and regulations governing appeals do not allow the Plan to delay or postpone an appeal decision if additional information is requested but not received. For an expedited first-level appeal, a determination will be made within 72 hours of the request for the appeal. An expedited appeal is offered to the attending/ordering provider, patient/member and facility when a determination is made not to certify services and the situation meets the requirements for an expedited appeal as defined by BCBSNE. An expedited appeal may be submitted in writing or verbally by calling us at 402-982-8314 or toll free 877-448-3339. If additional information was requested but not received, the appeal decision will be made based on the information available. For a non-expedited first-level appeal, a decision will be made on either the 15th working day or 30th calendar day (depending upon the group’s contract) from receipt of the appeal request.

The attending provider will be notified of the appeal determination within 72 hours of the request for the appeal when care is expedited. Written notification of the appeal determination will be sent for 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 of benefits letter following the first level of appeal will provide the necessary information and the process to request a second level of appeal, when the second level appeal is available.

If the second-level appeal results in a denial of benefits, then the appeal process at BCBSNE has been 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.}