Nebraska § 44-5435 - Adverse determinations; utilization review agent; procedure.

§ 44-5435. Adverse determinations; utilization review agent; procedure.

(1) A utilization review agent shall ensure that all adverse determinations for prior authorization are made by a physician, except that if the requesting health care provider is not a physician, the adverse determination may be made by a clinical peer of the requesting health care provider. Such physician or clinical peer shall:

(a) Possess a current and valid nonrestricted license in a United States jurisdiction;

(b) Have the appropriate training, knowledge, or expertise to apply appropriate clinical guidelines to the health care service being requested; and

(c) Make the adverse determination under the clinical direction of one of the utilization review agent's medical directors who is responsible for the provision of health care services provided to enrollees of Nebraska. All such medical directors must be physicians licensed in a United States jurisdiction.

(2) When an adverse determination for prior authorization is issued or a prior authorization is canceled or voided, the utilization review agent shall provide notice to the requesting health care provider. The notice shall include the reason for denial, citing written clinical review criteria.

(3)(a) If an adverse determination for prior authorization questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the enrollee's health care provider shall have the opportunity to discuss the health care service with the physician or clinical peer who is responsible for determining authorization of the health care service under review. The enrollee's health care provider may request that such discussion occur within three business days after receiving notice of the adverse determination. No discussion shall be required or allowed for an adverse determination that is due to contract exclusions or benefits that are not covered by the health benefit plan.

(b) Following any discussion under subdivision (3)(a) of this section, the utilization review agent shall notify the requesting health care provider whether the adverse determination decision remains the same. The notice under this subdivision shall be provided (i) within one business day after the discussion under subdivision (3)(a) of this section for an urgent health care service or (ii) within two business days after the discussion under subdivision (3)(a) of this section for a nonurgent health care service.

(c) A discussion under subdivision (3)(a) of this section shall not replace or eliminate the opportunity for any internal grievance or appeal process provided by the utilization review agent.