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.

Incorrect!

If you file a claim and your health plan denies the claim, you then the Health Carrier Grievance Procedure Act, Neb. Rev. Stat. §§ 44-7301 to 44-7315, gives you the  right to file an “internal appeal.”

Correct!

The external review process does not apply to specified disease, specified accident, accident only, credit, dental, disability, hospital indemnity, long-term care, vision care, Medicare supplement, workers’ compensation or automobile medical payment plans.

“Grandfathered” health plans—plans that were in existence on March 23, 2010 and have not substantially changed—are also not subject to external review requirements.

If your coverage is obtained through a self-insured plan please contact your employer’s benefits coordinator for information on the appeals process.