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.

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. 

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.

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

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.

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.