Administrative Denials

The administrative determination appeal process affords providers and practitioners one level of appeal for coverage determinations related to administrative denials. 

Administrative denials are determinations made by Blue Cross and Blue Shield of Nebraska (BCBSNE) in accordance with administrative policies and procedures and/or contract language. These determinations are not based on medical necessity or appropriateness. 

Administrative denials can be issued by BCBSNE with or without review by a plan medical director. An administrative denial is applied when there is provider noncompliance with providing clinical information needed to render a decision for inpatient admission.