BlueCross BlueShield Nebraska Reconsideration Request

To submit the reconsideration request form, you can send it via multiple channels. For electronic submission, use NaviNet to upload the completed document directly. Alternatively, you may mail the form to Blue Cross and Blue Shield of Nebraska, Attention: HNR/Reimbursements, PO Box 3248, Omaha NE 68180-0001. If you prefer fax submission, send it to 402-548-4698. Be sure to confirm that all necessary documentation is attached before sending your request.

The reconsideration request form is crucial for submitting claims that require review beyond standard processing. In 2024, ensure timely submissions, particularly around peak insurance claims periods. Stay updated on any modifications to requirements or deadlines.

The purpose of the reconsideration request form is to provide members and providers a way to formally ask BlueCross BlueShield of Nebraska to review a claim that has been previously processed. This form allows for the inclusion of additional documentation and information that may not have been considered initially. Completing the form accurately and promptly can facilitate the resolution of claim disputes and ensure proper reimbursement.

• 1. Member's Name: Enter the name of the member associated with the claim.
• 2. Member's ID Number: Provide the insurance identification number of the member.
• 3. BCBSNE Claim Number: Indicate the claim number assigned by BCBSNE.
• 4. Provider Name: List the name of the healthcare provider.
• 5. Individual NPI: Enter the National Provider Identifier for the individual provider.
• 6. Contact Name: Name of the individual who can be contacted for more information.
• 7. Phone Number: Provide a phone number for communication regarding the claim.
• 8. Patient's Name: Indicate the name of the patient receiving services.
• 9. Relationship: Describe the relationship of the member to the patient.
• 10. Date(s) of Service: The date(s) when the medical services were provided.
• 11. Location of Services: Specify where the services were rendered.
• 12. Clinic Tax ID or NPI: Mandatory identifier for the clinic providing services.
• 13. Address: Mailing address of the member or provider.
• 14. Fax Number: Fax number for sending additional documents, if required.
• 15. Reason for Reconsideration: Checkbox options for selecting the reason for the reconsideration.
• 16. Comments: Space for any additional comments or information relevant to the reconsideration.

Failing to submit the reconsideration request form properly can lead to claim denial. It is crucial to provide all requested information to avoid delays. Incomplete submissions may prevent your case from being reviewed.

• Delayed Review: Incomplete forms may result in delays in the reconsideration process.
• Claim Denial: Failure to follow submission guidelines may lead to automatic claim denials.
• Increased Workload: Retrieving and completing forms again increases workload for both the member and provider.

• 1. Claim Denial Appeals: Use this form to formally appeal a claim that has been denied.
• 2. Correcting Errors: When errors are identified in processed claims, this form is required to initiate corrections.
• 3. Providing Additional Information: Submit this form if you have new documentation supporting your claim.