§ 44-7310 — Standard review of adverse determinations

(1) A health carrier
shall establish written procedures for a standard review of an adverse determination.
Review procedures shall be available to a covered person and to the provider
acting on behalf of a covered person. For purposes of this section, covered
person includes the representative of a covered person.
(2) When reasonably necessary or when requested by the provider
acting on behalf of a covered person, standard reviews shall be evaluated
by an appropriate clinical peer or peers in the same or similar specialty
as would typically manage the case being reviewed. The clinical peer shall
not have been involved in the initial adverse determination.
(3) For standard reviews the health carrier shall notify in
writing both the covered person and the attending or ordering provider of
the decision within fifteen working days after the request for a review. The
written decision shall contain the provisions required in subsection (3) of
section 44-7308 .
(4) In any case in which the standard review process does
not resolve a difference of opinion between the health carrier and the covered
person or the provider acting on behalf of the covered person, the covered
person or the provider acting on behalf of the covered person may submit a
written grievance, unless the provider is prohibited from filing a grievance
by federal or other state law.

Legislative History

Source: Laws 1998, LB 1162, § 75; Laws 2013, LB147, § 21.