Appeals

Questions may come up about the member’s health benefit plan.  Most questions can be answered by contacting Nevada Health Solutions at 702-216-1653 or call the toll free number at 855-392-0778.

Information about the Appeal process may be obtained by contacting Nevada Health Solutions or your Health Plan’s Customer Service Department.

APPEAL PROCESS

If a Nevada Health Solutions physician reviewer determines that the services requested does not meet medical necessity clinical criteria and sends an adverse determination letter, there are steps the member/ member’s representative, provider or facility may take to have a different physician reviewer consider the request for services.  This is called an Appeal.

FIRST LEVEL APPEAL

A member/member’s representative, provider or facility may appeal any adverse determination either orally, electronically or in writing within one hundred eight (180) days of receipt of the adverse determination.   Written First Level Appeal review requests should be mailed to:

Nevada Health Solutions
P.O. Box 61440
Las Vegas, Nevada 89160

When you file an appeal, be sure to let us know any new information you have that will help us make our decision. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make the decision.

When reviewing your appeal, we will:

  • Use providers who know about the type of illness you have
  • Not use the same people who denied your request for a service
  • Make a decision about your appeal within fifteen (15) calendar days for a pre-service adverse determination or thirty (30) calendar days for a post service adverse determination.
  • Provide the appeal decision in writing in easily understandable language.

An expedited appeal is a request for review of emergency care, care for life-threatening conditions, or continued stays for hospitalized patients.  An expedited appeal decision is made within seventy two (72) hours of the request for appeal.

LEGAL RIGHTS

If the member’s health benefit plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA, and all internal levels of appeals have been exhausted, the member has a right to bring a civil action under 502 (a) of ERISA.

If the member’s health benefit plan is not subject to ERISA and the member has a life expectancy of less than two years and the proposed services were considered experimental/investigational, the member may seek information regarding an external appeal process administered by the Insurance Department.

OTHER MEMBER RIGHTS

  • The member is entitled to receive upon request and free of charge any documents, records, and other information about the member’s claim for services including criteria and/or specialty of any consultant used to make the decision.
  • The member must first exhaust all of the Nevada Health Solutions  internal appeal mechanisms
  • In an emergency or life threatening situation, the member or provider acting on behalf of the member with the member’s consent, would not need to exhaust all internal appeals in order to file for an external appeal.  The expedited appeal application may be filed with the Insurance Department at any level of the appeal.
  • If the expedited external appeal is not accepted, and the member has not previously exhausted all internal appeals, the member may resume the internal appeal process until all internal appeals are exhausted and then may file for a standard external appeal within 60 days following receipt of the final non certification letter.
  • If all internal appeals were previously exhausted, the member’s rejected expedited external appeal will automatically be eligible for consideration for standard external appeal.  The member is not required to submit a new application.
  • If you need assistance filing your appeal, you may contact the Consumer Assistance Programin the State you reside to locate the contact information.