External Review Request Form for Health Insurance

To submit the External Review Request Form, complete all required fields and ensure everything is accurate. Mail the completed form to the Nebraska Department of Insurance at PO Box 82089, Lincoln, NE 68501-2089. For immediate assistance, you may also contact them at (877) 564-7323.

Important dates for filing the External Review Request Form are within four months of receiving a denial from your insurer. Keep track of any updates regarding your request. It's crucial to submit the appeal timely to ensure your rights are protected.

The purpose of this form is to provide a structured way for individuals to contest denials of health insurance claims. By completing this form, covered persons can request an external review of their claims, potentially leading to reimbursement for denied services. This process ensures that patients have recourse to correct insurance errors or misunderstandings.

• 1. Applicant Name: Indicates who is filling out the form, such as the covered person or authorized representative.
• 2. Covered Person Information: Contains personal details of the individual who is contesting the claim.
• 3. Insurance Information: Details pertaining to the insurance policy and the claim in question.
• 4. Employer Information: Information regarding the employer if the health plan is employer-sponsored.
• 5. Health Care Provider Information: Details about the treating health care provider involved in the claim.
• 6. Reason for Denial: Checkbox options for selecting the reason the health carrier denied the claim.
• 7. Signature: A section for the covered person to sign and authorize the release of medical records.
• 8. Appointment of Authorized Representative: Section to designate a representative if the covered person is not filling out the form themselves.

If the form is not submitted, the covered person may lose their right to appeal the claim denial. This could result in the healthcare services not being reimbursed, impacting financial stability. It's essential to adhere to the submission guidelines to maintain the opportunity for outside review.

• Loss of Appeal Rights: Failing to submit the form may lead to forfeiting your ability to contest the insurer's decision.
• Continued Financial Burden: Without a successful appeal, you may incur out-of-pocket expenses for denied healthcare services.
• Delayed Care Decision: Not submitting the form will delay any decisions on necessary treatments that were denied.

• 1. Claim Denial Appeal: Use this form to appeal any denied claims from your health insurer.
• 2. Expedited Review Request: Request an expedited review if the delay could jeopardize patient health.
• 3. Authorized Representation: Employ this form if you wish to have someone represent you during the appeal process.