Process to Appeal Post-Payment Provider Audit Findings

Level I Appeal Process 

The provider is required to submit a written appeal to Blue Cross and Blue Shield of Nebraska (BCBSNE). The appeal must state the specific reason for the dispute. Send the appeal and all required supporting documentation to the following address:  

Blue Cross and Blue Shield of Nebraska
ATTN: Provider Audit 
P.O. Box 3248  
Omaha, NE 68180-0001  

Required supporting documentation:  

1. The appeal must be accompanied by any new or additional documentation from provider records to substantiate the provider’s position. This additional information must meet the following criteria:
   1. The information must be relevant to the disputed issue(s).  
   2. The information must have existed during the dates of service for the record(s) in question.  
   3. The information must provide evidence-based supporting documentation.  
2. If the appeal contests the case-review decision of the BCBSNE medical director or other BCBSNE physician consultant, the provider must provide its medical staff member or medical consultant with a written reply to BCBSNE for case review.  
3. Peer-reviewed medical literature and other expert opinions may be included.  

Level II Appeal Process  

Upon communication of the level I appeal results, the provider has an additional 14 calendar days to submit a written notice of second appeal with additional supporting documentation for review by provider audit staff. If the dispute is still unresolved, provider audit staff will forward the documentation to the BCBSNE medical director or other BCBSNE physician consultant. Once the BCBSNE physician/medical director’s decision is made, documentation for that decision will be returned to the Provider Audit department to communicate the appeal results back to the provider. 

Provider Audit Provisions

1. All BCBSNE Provider Procedures, medical policy, and provider agreements are considered while reviewing medical records. BCBSNE medical policy includes but is not limited to medical necessity policy and investigative policy.  
2. In no case will an audit be scheduled beyond the refund time limit specified in the Refund/Offsetting section of the applicable provider agreement, unless there is a reasonable belief of fraud, waste and abuse (FWA).  
3. Once a claim has been selected for audit review, the provider should not submit a replacement or corrected electronic or paper claim, nor should one be submitted at any time during or after the review process.  
4. Standing orders or care protocols must be available for review.  
5. Charges for nursing and/or ancillary personnel care that do not include supplies are not considered billable services and will be removed from the charges prior to calculation of negotiated reimbursement methodology. These services are not billable to the member.  
6. Issues identifying a lack of appropriate documentation to support billed charges may result in recommendations by our staff to address a corrective action plan or disallowance of the charges billed. These recommendations are noted in the Final Report Letter.  
7. When BCBSNE medical policy determines an item or service to be investigative, experimental or not medically necessary, the item(s) or service(s) considered noncovered services will be deemed provider liability.  

Examples of Nonbillable Facility Charges

The list below contains examples of nonbillable facility component charges. This list is NOT an all-inclusive list of nonbillable charges. Nonbillable charges are removed from the total charges before calculating reimbursement. Nonbillable services may not be billed to the member.  

Nonbillable Services  

• Administration of blood products or medications  
• After-hours, on-call, stand-by, emergency call or stat charges - e.g., lab, EKG/EEGs, x-ray, CT scan, ultrasound, nuclear medicine, operating room.  
• Blood service charges  
• Bone marrow collection or aspiration  
• Bronchoscopy assists  
• Catheterization technical services  
• Charges for nursing and/or ancillary personnel care that do not include supplies  
• Code 99, CPR or unscheduled cardioversion  
• Emergency room (ER) patient assist or transport  
• Extubating/intubation  
• Insertion of catheters, i.e., arterial, Groshong, central line, PICC, IV, foley, nasogastric  
• Incentive spirometry or metered dose inhaler (MDI) treatment  
• Kinetic consult or monitoring  
• Manual ventilation  
• Medication mixing fees  
• Nasal tracheal, tracheal tube suction or aspiration, cough induction, suctioning, secretion induction  
• Obtaining blood specimen, any method, for inpatient lab testing  
• Patient assessment  
• Patient assistance  
• Patient education or teaching  
• Patient transportation  
• Pathology tech assist or slide preparation  
• Peritoneal lavage procedure  
• Set-up charges e.g., ventilators, arterial lines, oximetry, etc.  
• Swab specimen collection  
• Therapist assist; PT/OT/Speech, Respiratory Therapist  
• Vital sign monitoring including oximetry and/or CO2 monitoring/capnography  
• Duplication of therapeutic services