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. 

Question 18

Question

Is there additional paperwork required for an expedited review?

Yes Answer

Correct!

There is a separate form in the external review paperwork that your physician needs to sign to verify that your condition does require an expedited review.

 

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.
No Answer

Incorrect!

There is a separate form in the external review paperwork that your physician needs to sign to verify that your condition does require an expedited review.

 

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.

Question 17

Question

Does a standard external review take 45 days? 

Yes Answer

Correct!

The Independent Review Organization (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.  The notice will include the reason for the decision, any evidence-based standards that were a basis for the decision and references to evidence or documents considered in reaching the decision.

How long to decide expedited

No Answer

Incorrect!

The Independent Review Organization (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.  The notice will include the reason for the decision, any evidence-based standards that were a basis for the decision and references to evidence or documents considered in reaching the decision.

How long to decide expedited

Question 16

Question

Is there a timeframe to file an external review?

Yes Answer

Correct!

You have four months from the date you receive a denial notice to request external review. Your insurer will provide you with an external review request form, or you can obtain the form on the Department web site.  Instructions for submitting the external review request are included on the form.

Please be sure to complete all required fields and sign the form. Your signature is required.

  • If you want to appoint an authorized representative, including your health care provider, the external review paperwork includes a form for you to use.
  • If you request expedited external review or you challenge a denial of an experimental or investigational medical treatment, there are additional pages in the external request that your physician must complete.
No Answer

Incorrect!

You have four months from the date you receive a denial notice to request external review. Your insurer will provide you with an external review request form, or you can obtain the form on the Department web site.  Instructions for submitting the external review request are included on the form.

Please be sure to complete all required fields and sign the form. Your signature is required.

  • If you want to appoint an authorized representative, including your health care provider, the external review paperwork includes a form for you to use.
  • If you request expedited external review or you challenge a denial of an experimental or investigational medical treatment, there are additional pages in the external request that your physician must complete.