You must submit your request for external review to the Nebraska Department of Insurance (“Department”) within four months from when your insurer sent you the final decision.[5] Your health insurer should have provided you with a copy of the external review request form with your determination letter.[6] You can also find a copy of the external review request form here.

Information. You should include the following information with your request:

  • Name of applicant;
  • Name, address, and telephone number of the insured person;
  • Name of the patient;
  • Name, address, and telephone number of the health insurer;
  • Insurance identification number, claim or reference number;
  • Employer name and telephone number;
  • Name and address of your treating physician or health care provider;
  • The name and telephone number of the contact person at your provider’s office;
  • Your medical record number;
  • The reason for denial;
  • Brief description of the claim; and
  • Description of the health care service or treatment in dispute.[7]

Supporting documents. You should also include the following supporting documents with your request:

  • A copy of your insurance card or other evidence showing coverage;
  • A copy of the final determination letter from your health insurer;
  • A copy of your insurance policy; and
  • Any additional information or documentation not included with your request for an internal appeal.[8]

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

Nebraska Department of Insurance
P.O. Box 82089
Lincoln, NE 68501-2089[9]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Department at (877) 564-7323 for instructions on the fastest way to submit your request and supporting documentation.[10]