Members Held Harmless

In accordance with their affiliation agreement, providers may not seek payment from members for elective services that have not been approved by Blue Cross and Blue Shield of Nebraska (BCBSNE) unless the member is informed in advance regarding their payment responsibility. 

Some of the circumstances in which members are held harmless for denied covered services include: 

• Urgent/emergent admission denials 
• Partial denial of a hospital stay 
• Requests for elective services provided by contracted providers that require clinical review but were not forwarded to BCBSNE prior to the service being rendered 
• Denials issued for post-service requests for services provided by contracted providers when the information submitted is not substantiated in the medical record 

Members at Risk 
In certain instances, members are held at financial risk for denied services. These instances occur when: 

• The member’s contract was not in effect on the date of service 
• The member refuses to leave an inpatient setting after the attending physician has discharged the member 
• A denial has been issued for pre-certified services 
• Services are rendered that are not a covered benefit under the member’s certificate