Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 87 - HEALTH CARRIER EXTERNAL REVIEW › Appendix A - Notice of Appeal Rights

Current through June 17, 2024
NOTICE OF APPEAL RIGHTS
You have a right to appeal any decision we make that
				  denies payment on your claim or your request for coverage of a health care
				  service or treatment.
You may request more explanation when your claim or
				  request for coverage of a health care service or treatment is denied or the
				  health care service or treatment you received was not fully covered.
Contact1 us when you:
* Do not understand the reason for the denial;
* Do not understand why the health care service or treatment
				  was not fully covered;
* Do not understand why a request for coverage of a health
				  care service or treatment was denied;
* Cannot find the applicable provision in your Benefit Plan
				  Document;
* Want a copy (free of charge) of the guideline, criteria or
				  clinical rationale that we used to make our decision; or
* Disagree with the denial or the amount not covered and you
				  want to appeal.
If your claim was denied due to missing or incomplete
				  information, you or your health care provider may resubmit the claim to us with
				  the necessary information to complete the claim.1
Appeals
: All appeals for claim denials (or any
				  decision that does not cover expenses you believe should have been covered)
				  must be sent to [health carrier to insert address of where appeals should be
				  sent to the health carrier] within
180 days
of the date you
				  receive our denial.2 We will provide a full and fair
				  review of your claim by individuals associated with us, but who were not
				  involved in making the initial denial of your claim. You may provide us with
				  additional information that relates to your claim and you may request copies of
				  information that we have that pertains to your claims. We will notify you of
				  our decision in writing within
30 days
of receiving your
				  appeal.3 If you do not receive our decision within
30 days
of receiving your appeal3, you
				  may be entitled to file a request for external review.
External Review
: We have denied your request for
				  the provision of or payment for a health care service or course of treatment.
				  Once you have completed the internal grievance or appeals process as set forth
				  above, you may be entitled to a standard external review of your claim denial
				  if our decision involved making a judgment as to the medical necessity,
				  experimental or investigational nature, appropriateness, health care setting,
				  level of care or effectiveness of the health care service or treatment you
				  requested. You may submit a request for external review within 4 months after
				  receipt of this notice to the Nebraska Department of Insurance at Nebraska
				  Department of Insurance, PO Box 82089, Lincoln, NE 68501-2089. You may
				  telephone the Department of Insurance for more information at (877) 564-7323.
				  The form required to request an external appeal will be provided with a final
				  adverse benefit determination. In addition, the forms may be accessed on our
				  website or on the Department of Insurance Website at
www.doi.nebraska.gov
. For standard
				  external reviews, a decision will be made within
45 days
of
				  receiving your request. You may be entitled to an
expedited external
				  review
of an adverse determination. If you have a medical condition that
				  would seriously jeopardize your life or health or would jeopardize your ability
				  to regain maximum function if treatment is delayed, and our denial to provide
				  or pay for health care service or course of treatment is based on a
				  determination that the service or treatment is experimental or investigational,
				  you may be entitled to file a request for expedited external review of our
				  denial, upon certification by your treating physician. You may not have to
				  complete the internal appeals process to request an expedited external review.
				  The expedited external review may be requested once the internal appeal has
				  been submitted. For details, please review your Benefit Plan Document, contact
				  us or contact the Nebraska Department of Insurance.
1 See address and telephone number
				  on the enclosed Explanation of Benefits if you have questions about this
				  notice.
2 Unless your plan or any
				  applicable state law allows you additional time.
3 Some states and plans allow you
				  more (or less) time to file an appeal and less (or more) time for our decision.
				  See your Benefit Plan Document for your state's internal appeal
				  process.