Appealing a Denied Health Claim

Click HERE to access the External Review Secure Portal Instructions are provided at the bottom of this page for people filing an external review and stakeholders providing information as part of an external review.

Appealing a Denied Health Claim

If your insurer or HMO denies health care services as not medically necessary, experimental/investigational or cosmetic, you have the right to request an External Review through the Nebraska Department of Insurance.

The Health Carrier External Review Act, Neb. Rev. Stat. §§ 44-1301 to 44-1318, gives you the opportunity for a neutral third party to review a denied claim.

*Please note, self-funded (self-insured) benefit plans are not under the jurisdiction of the Nebraska Department of Insurance, and are therefore ineligible for external review through the State of Nebraska. For external review options for self-funded plans, please contact your employer’s benefits coordinator.

For Medicare/Medicaid Appeals

The State of Nebraska external review process does not apply to Medicare/Medicaid plans.  Please visit the links below to learn more about appeals for Medicare/Medicaid plans.

Medicare: https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal

Medicaid: http://dhhs.ne.gov/Pages/Medicaid-Services.aspx

Types of denials that are eligible for external review

· A determination that a covered health care service does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or

· A denial for the reason that a treatment is experimental or investigational.

The Explanation of Benefits denying the claim or the initial appeal decision from your insurer will state the basis for a denial.

What if the denied medical service or drug is not covered?

· If the insurer denies your claim based on a policy exclusion, the insurer must tell you which provision is the basis for the denial.

· If the exclusion is for investigational or experimental treatment, you still qualify for external review.

· Check your policy’s appeals section for details. If you have an individual or small group policy, federal law gives you the right to ask your insurer to cover a drug that does not appear on the insurer’s formulary.

 

Steps in the external review process

1. Internal Appeals: Complete internal appeals with your insurance carrier. Cases are only eligible for an external review once the internal appeals process with the insurer has been exhausted.  Check with your insurance carrier for details on levels of internal appeals and for clarification if these have been exhausted if you are unsure.

2. Initial Paperwork: You have four months from the date you receive a denial notice to request an external review. Your external review can be completed through the external review secure portal, which will allow you to check on the status of the external review at any time, and which will send you an email notice of each event occurring as the external review progresses, as well as an emailed determination immediately when the external review is complete.

If you do not wish to type information into the portal, the forms for an external review are available for printing below.  Your external review will be processed through the portal once the Department of Insurance receives your documents by mail or fax.  An external review specialist from the Department will contact you to determine if you would rather receive the final external review determination by mail or receive ongoing updates from the portal to your email. Instructions for submitting the external review request on paper are included on the printable form.

Whether you use the secure portal or the printable external review forms, please be sure to complete all required fields and sign the form. Your signature is required, and incomplete forms will be returned.

· The external review portal allows you to appoint an authorized representative as part of your application for an appeal.  Similarly, the  External Review Form includes a space for you to appoint an authorized representative.

· The external review portal allows you to request an expedited external review or challenge a denial of an experimental or investigational medical treatment, which will involve contacting your healthcare provider for them to provide information.  Please contact your healthcare provider and obtain an email address to type into the portal – notice will be sent to your healthcare provider using that email, and your healthcare provider can then type information directly into the portal.  In the alternative, you can print either or both of these forms, ask your healthcare provider to complete them, and send them to the Department or upload them into the portal. 

3. Eligibility Determination: A preliminary review will determine whether the request is complete and whether the request is eligible for external review.

4. Independent Review: Complete and eligible requests will be assigned to an independent review organization (“IRO”). The IRO will also consider your medical records, doctor’s recommendation, insurance policy, and other medical or clinical data.

5. Decision: The IRO will provide a written notice to uphold or reverse the insurer’s claim denial within 45 days after receipt of your external review request (72 hours for expedited requests).

Expedited review

An Expedited external review takes no longer than 72 hours and is available if:

· Your doctor can certify that you need an expedited review in urgent situations when waiting 45 days would jeopardize your life or health, or if waiting 45 days would jeopardize your ability to regain maximum function; or

· You are appealing a decision about admission, availability of care, continued stay, or health care service for which you received emergency services, but have not been discharged from a facility.

 

To obtain an expedited review

If you meet the above criteria and would like to submit a request for an expedited appeal, you must obtain the physician certification, either via an email alert within the External Review Portal or via a signed and submitted document  Expedited Review Form containing the physician’s signature.

 

Helpful Information to Include with Request

Keep copies of all information related to your claim and the denial; both the information you submit and the responses you receive. If necessary, you can request copies of your entire claim file free of charge from the insurance company. Examples of important records are:

· The Explanation of Benefits forms or letters showing what payment or services were denied, and why.

· A dated copy of the request for an internal appeal that you sent to your insurance company.

· Any additional information you sent to the insurance company; for example, a letter or medical records from your doctor.

· A copy of any letter or form you signed authorizing your doctor or anyone else to file an appeal for you.

· Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.

· Peer-reviewed medical literature relevant to the determination

 

Questions?

For questions or help with an application, you may contact the Nebraska Department of Insurance at:

Nebraska Department of Insurance

1135 M St. Suite #300

Phone: (402) 471-2201

 

External Review Application Paper Copy

If you prefer to submit a hard copy application, you can find the application at the link below.

Forms and/or Assistance in Other Languages

Please contact the Nebraska Department of Insurance at (402) 471-2201

 

Resources

External Review Secure Portal 

Notice to Carriers, Implementation of Portal for Processing External Reviews View Notice

Secure Portal User Help Guides:

Initial Paperwork (these are incorporated into the portal, including the healthcare provider forms):