Network Termination and Non-Payable Status

Blue Cross and Blue Shield of Nebraska (BCBSNE) may terminate a contracted physician, facility or other health care provider (provider) from plan networks and/or place them in a non-payable status, with or without cause, based on contract provisions of the Provider Agreement.

In addition, BCBSNE may require termination of a provider if the provider:  

• Submits a pattern of claims which willfully and intentionally misrepresent the services provided or the charge for such service, or demonstrates a pattern of fraud, waste and abuse (FWA).
• No longer maintains the applicable unrestricted state or federal license.
• No longer provides services to patients within the state of Nebraska; or has not submitted claims to BCBSNE in the past 18 months.  
• Is convicted of a felony or is expelled or suspended from the Medicare or Medicaid programs (Title XVIII or XIX of the Social Security Act).  

Subject to applicable laws, such provider may be given an opportunity to enter and complete a corrective action plan (CAP) prior to termination. Participation in a CAP exhausts one level of appeal. No corrective action is available in cases of fraud, imminent harm to patient health or when the provider’s ability to provide services has been restricted by action, including probation or any compliance agreement, by the Nebraska Department of Health or other governmental agency. When the provider’s attempt to correct the situation is insufficient, the provider’s participation with BCBSNE will be terminated. Since participation in a CAP exhausts one appeal right, only one appeal remains following the completion of a CAP.