External Review

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

Appealing a Denied Health Claim

Health Carrier External Review Act

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. 

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

Types of denials that are eligible for external reveiw

  • 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. 

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 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 

3. Eligibility Determination

A preliminary review will determine whether the request is complete and whether the request is eligible for external review. 

  • Reasons that request may be deemed ineligible include:
    • ​The internal appeal process was not completed 
    • The denial was for a reason other than medical necessity (ex: out-of-network provider/facility, contract exclusion, or denials for a deductible not being met)
    • External review forms are not complete 
    • The plan is a self-insured plan 
    • The plan is domiciled in another state 
    • The timeframe for filing an appeal (180 days) or external review request (4 months) has passed
  • ​Please verify that none of the above exclusions apply 

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 external review request (72 hours for expedited requests).

Expedited review

When is an expedited review available?

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

  • Your doctor can certify that you need 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 Expedited Review Form containing the physician's signature included with your signed External Review Form

Resources

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 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 

Questions?

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

Nebraska Department of Insurance
P.O. Box 95087

Lincoln, NE 68509-5087
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. 

Initial Paperwork:

Forms and/or Assistance in Other Languages

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

Portal Resources

External Review Secure Portal 

Notice to Carriers, Implementation of Portal for Processing External Reviews

Secure Portal User Help Guides:

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