Denied Health Claim Quiz
This quiz is designed to help you understand the process of appealing a denied health claim and answers many common questions about the same.
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
