Network Termination – Non-Appealable Decisions

Non-appealable issues include, but are not limited to:

• Contracting requirements for networks:
  • Lack of privileges at a contracting facility  
  • Lack of covering contracting practitioners  
  • Not participating in the organized delivery system or group model  
  • No geographic need  
  • No need for specialty  
  • Change in practice affiliation or location  
• If the provider’s license to practice is currently revoked, terminated or suspended 
• If the practitioner’s Federal Drug Enforcement Administration or Centers for Disease Control and Prevention issued number is currently revoked or suspended (if it is required for practitioner’s profession) 
• If the provider is convicted of a felony or is expelled or suspended from Medicare or Medicaid programs (Title XVIII or XIX of the Social Security Act) 
• If the provider’s professional liability insurance coverage does not meet the coverage requirements of Blue Cross and Blue Shield of Nebraska  
• Any material misrepresentation made by the provider during network participation 
• Primary office location is not in Nebraska or contiguous county 
• Lack of office facility, cessation of business or insolvency of the provider