Correct!

If the insurer denies your claim based on a policy exclusion, the insurer must tell you which provision is the basis for the denial.  Typically, you cannot use external review to get coverage for a treatment that is excluded under the policy.  But be aware of some special rules:

• If the exclusion is for investigational or experimental treatment, you still qualify for external review. 
• If the exclusion is for cosmetic procedures, but your doctor’s position is that this treatment is medically necessary, then there is a disagreement about whether the exclusion applies, and you still qualify for external review.
• 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.  Check your policy’s appeals section for details.

Correct!

Denials based on medical decision-making are eligible for external review, specifically:

• A determination that a covered health care service does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or
• A denial for the reason that a treatment is experimental or investigational.

Correct!

An Independent Review Organization (IRO) is an independent third party that is accredited and decides every external review.

The IRO considers your medical records, doctor’s recommendation, insurance policy, and other medical or clinical data when making their decision. 

Incorrect!

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.  

Correct!

At the end of the internal appeal process, your insurance company must provide you with a written decision.  For certain types of claim denials, if your insurance company still denies a service or payment for a claim, you can ask for an external review. The insurance company’s final determination must tell you how to ask for an external review.

When you receive the final adverse determination for your internal appeal your Insurer is required to provide the Nebraska Department of Insurance’s external review request forms. 

Incorrect!

Your internal appeal must be completed within 15 working days after the insurance company received your request for review. For some claims, if the insurer cannot complete the review within 15 working days, it may take up to an additional 15 working days.

Incorrect!

As the claimant, you have the burden to prove your claim should be paid.  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 file an appeal for you.
• Notes and dates from any phone conversations you have with your 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.

Incorrect!

To file an internal appeal, you need to complete all forms required by your health insurer, or you can write to your insurer with your name, claim number, and health insurance ID number.  Submit any additional information you want the insurer to consider, to help explain why you believe the company’s decision was wrong. Often a letter from the doctor explaining by the requested treatment or procedure is “medically necessary” will assist the insurer in reconsidering your claim.

Incorrect!

Insurers must give consumers notice of their right to appeal a denied claim.  You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.

Incorrect!

Denial reasons can include:

• The benefit isn’t offered under your health plan;
• You received health services from a health provider or facility that isn’t in your plan’s approved network;
• The requested service or treatment is “not medically necessary”;
• The requested service or treatment is an “experimental” or “investigative” treatment;
• You’re no longer enrolled or eligible to be enrolled in the health plan; or
• It is revoking or canceling your coverage going back to the date you enrolled because the insurance company claims that you gave false or incomplete information when you applied for coverage.