This text of Nebraska § 44-7311 (Expedited reviews) is published on Counsel Stack Legal Research, covering Nebraska primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(1)A health carrier shall establish written procedures for
the expedited review of a grievance involving a situation in which the timeframe
of the standard grievance procedures set forth in sections 44-7308 to 44-7310
would seriously jeopardize the life or health of a covered person or would
jeopardize the covered person's ability to regain maximum function. A request
for an expedited review may be submitted orally or in writing. A request for
an expedited review of an adverse determination may be submitted orally or
in writing and shall be subject to the review procedures of this section,
if it meets the criteria of this section. However, for purposes of the grievance
register requirements of section 44-7306 , a request for an expedited review
shall not be included in the grievance
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(1) A health carrier shall establish written procedures for
the expedited review of a grievance involving a situation in which the timeframe
of the standard grievance procedures set forth in sections 44-7308 to 44-7310
would seriously jeopardize the life or health of a covered person or would
jeopardize the covered person's ability to regain maximum function. A request
for an expedited review may be submitted orally or in writing. A request for
an expedited review of an adverse determination may be submitted orally or
in writing and shall be subject to the review procedures of this section,
if it meets the criteria of this section. However, for purposes of the grievance
register requirements of section 44-7306 , a request for an expedited review
shall not be included in the grievance register unless the request is submitted
in writing. Expedited 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) Expedited reviews which result in an adverse determination
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 or peers shall not have been involved in the initial adverse determination.
(3) A health carrier shall provide expedited review to all
requests concerning an admission, availability of care, continued stay, or
health care service for a covered person who has received emergency services
but has not been discharged from a facility.
(4) An expedited review may be initiated by a covered person
or a provider acting on behalf of a covered person.
(5) In an expedited review, all necessary information, including
the health carrier's decision, shall be transmitted between the health carrier
and the covered person or the provider acting on behalf of a covered person
by telephone, facsimile, or the most expeditious method available.
(6) In an expedited review, a health carrier shall make a
decision and notify the covered person or the provider acting on behalf of
the covered person as expeditiously as the covered person's medical condition
requires, but in no event more than seventy-two hours after the review is
commenced. If the expedited review is a concurrent review determination, the
health care service shall be continued without liability to the covered person
until the covered person has been notified of the determination.
(7) A health carrier shall provide written confirmation of
its decision concerning an expedited review within two working days after
providing notification of that decision, if the initial notification was not
in writing. The written decision shall contain the provisions required in
subsection (3) of section 44-7308 .
(8) A health carrier shall provide reasonable access, not
to exceed one business day after receiving a request for an expedited review,
to a clinical peer who can perform the expedited review.
(9) In any case in which the expedited 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. Except as expressly provided in this section, in conducting
the review, the health carrier shall adhere to timeframes that are reasonable
under the circumstances.
(10) A health carrier shall not be required to provide an
expedited review for retrospective adverse determinations.