External Appeals for Insured Plans in Nebraska

STATE OF NEBRASKA Dave Heineman Governor DEPARTMENT OF INSURANCE Bruce R. Ramge Director 941 O Street, Suite 400 • PO Box 82089 • Lincoln, Nebraska 68501-2089 Phone (402) 471-2201 • Facsimile (402) 471-4610 • Website http://www.doi.ne.gov An Equal Opportunity/Affirmative Action Employer BULLETIN SUBJECT: External Appeals for Insured Plans in Nebraska The purpose of amending this bulletin is to alert all health insurers and insureds that since the issuance of CB-123, the federal government has issued amended rules and regulations regarding internal and external appeals. Insurers are strongly encouraged to read and review the changes to the rules and regulations and adjust accordingly. Following are relevant links to the additional regulations and guidance issued by the federal government: http://www.federalregister.gov/articles/2011/06/24/2011-15890/group-health-plans-andhealth-insurance-issuers-rules-relating-to-internal-claims-and-appeals-and http://www.dol.gov/ebsa/newsroom/tr11-02.html CB-123 was issued on September 15, 2010, to inform all health insurers and insureds that on September 1, 2010, the federal government provided additional guidance to states that do not have external review laws for adverse benefit decisions for health insurance plans. The language in CB-123 continued as follows: Nebraska does not have external review statutes. External review is the process by which an insured may appeal a claim denial or other adverse benefit decision to an Independent Review Organization that does not have an affiliation with the insurer. Beginning September 23, 2010, an insured will have the opportunity to not only go through an internal appeal process via the insurer but may also appeal, if necessary and at the option of the insured, that decision externally to an Independent Review Organization. Since Nebraska does not have an external law statute, the federal government, via the Office of Personnel Management (OPM), is assuming the responsibility of the external review process. The links found below outline not only what constitutes an adverse benefit decision, but the process for which that decision may be externally appealed. Insurers should note that they will be required to send to OPM, by September 23, 2010, the plans that are subject to external review and the name of a contact for urgent case external appeals. This information should be submitted to DisputedClaim@opm.gov. July 25, 2011 CB-123 (Amended) 1 of 2 WITHDRAWN CB-123 (Amended) July 25, 2011 Individuals who wish to avail themselves to an external appeal will need to contact OPM via email at DisputedClaim@opm.gov, via fax at (202) 606-0036, or via mail at PO Box 791, Washington, DC 20044. Please note that there are time limitations on when an external appeal may be requested. Additionally, in emergency situations, an expedited review is also available. Following are links to relevant documents issued by the federal government regarding external review. These links provide further guidance on the requirements of an external review and the process in which to request the external review: Link to the federal regulation regarding internal and external reviews: http://edocket.access.gpo.gov/2010/pdf/2010-18043.pdf Link to additional guidance on the process for an external review for those states, like Nebraska, that do not have a specific state statute on external review: http://www.hhs.gov/ociio/regulations/consumerappeals/interim_appeals_guidance.pdf Link to general outline of the information currently available from the federal government regarding internal and external review: http://www.hhs.gov/ociio/regulations/consumerappeals/index.html Additional questions about this amended bulletin may be directed to the Department’s Life and Health Division at 402-471-2201. Bruce R. Ramge Director 2 of 2 WITHDRAWN