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Nebraska health care providers may use this form to report insurer delays in payment of health claims submitted after January 1, 2006. Reports involving multiple claims submitted to a single insurer may be attached as a supplement and filed in paper format, but must include the plan type, the patient's name, the insured's or policyholder's name, the policy number, the claim number, the date of submission of the claim and a description of the problem for each individual claim. The Department of Insurance will not initiate an investigation based on the report form, but will record the information for monitoring purposes.
