Provider Request for an Advance Coverage Determination

Getting an Advance Coverage Determination  
(not related to services or items requiring pre-authorization/certification)  
Providers may choose to obtain a written advance coverage determination (also known as an organization determination) from us before providing a service or item.  

All Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage plans provide at least the same level of benefit coverage as Original Medicare (Part A and Part B). If the service or item provided meets Original Medicare medical necessity criteria, it will be covered by the plan.  

When the claim is submitted, it must still meet eligibility and benefit guidelines to be paid.  

To request an advance coverage determination, submit your request in writing by mail or fax to: 

BCBSNE will make a decision and notify you within 14 days of receiving the request, with a possible 14-day extension either due to the member’s request or BCBSNE justification that the delay is in the member’s best interest.  

In cases where you believe that waiting for a decision under this time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, fax your request indicating “Urgent” or “Expedite” on the first page of the request. We will notify you of our decision within 72 hours; unless a 14-day extension is requested by the member or the plan justifies a 14-day extension is in the best interest of the member.  

Be sure to include the following information with your request for an advance coverage determination:  

• Provider or supplier contact information including name and address 
• Anticipated date of service, if applicable 
• Procedure/HCPCS and Diagnosis codes 
• Pricing information, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code where services were rendered and physician specialty 
• Documentation and any correspondence that supports your position that the plan should cover the service or item (including clinical rationale, Local Coverage Determination and/or National Coverage Determination documentation) 
• Name and signature of the provider or provider’s representative