Appealing 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. 

Self-funded (self-insured) benefit plans are not under the jurisdiction of the NDOI, 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. 

• A determination that a covered health care services does not meet the insurer's requirements for medical necessity, 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. 

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 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 process 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 once the Department receives your documents by mail or fax. 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 

  • External Review Form

  • Expedited Review Form

  • Experimental or Investigational Review Form

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. 

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 Expedited Review Form containing the physician's signature included with your signed External Review Form. 

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 you 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 

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

Initial Paperwork:

• External Review Form

• Expedited Review Form

• Experimental or Investigational Review Form