Question 20
Question
Is the Independent Review Organization’s final determination binding?
Yes Answer
Correct!
The Health Carrier External Review Act, Neb. Rev. Stat. §§44-1311 states:
(1) An external review decision is binding on the health carrier except to the extent the health carrier has other remedies available under applicable state law.
(2) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.
(3) A covered person or the covered person's authorized representative, if applicable, shall not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to the Health Carrier External Review Act.
No Answer
Incorrect!
The Health Carrier External Review Act, Neb. Rev. Stat. §§44-1311 states:
(1) An external review decision is binding on the health carrier except to the extent the health carrier has other remedies available under applicable state law.
(2) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.
(3) A covered person or the covered person's authorized representative, if applicable, shall not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to the Health Carrier External Review Act.
Question 19
Question
When your insurer denies your treatment as “investigational” or “experimental”, do you have to provide additional forms for an external review?
Yes Answer
Correct!
There is a separate form in the external review paperwork that your physician needs to complete to verify that your denied claim is medically necessary and not experimental or investigational.
No Answer
Incorrect!
There is a separate form in the external review paperwork that your physician needs to complete to verify that your denied claim is medically necessary and not experimental or investigational.
