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]