Filing an Appeal
What is an appeal?
An appeal is when you ask us to review a decision we made about an authorization.
We may decide to deny, limit, reduce, or end an authorization for a service. This is called an "Adverse Benefit Determination." An appeal tells us you want us to look at the information again to make sure we made the right decision.
You have the right to file appeals. We will not treat you differently because you file an appeal.
If you need help filing your appeal call Member Service. The phone number is 1-844-385-2192 (Relay 711). We have people to help you Monday-Friday, 7 a.m. to 8 p.m., Central.
A member can file their own appeal, or they can designate another person to file it for them. If someone else is going to complete your appeal for you, we must have your written permission. No one can speak for you without your permission. To make someone else your representative for appeals compete the Authorized Representative Designation Form.
The forms should be faxed to Nebraska Total Care at 1-844-605-8372.
If there is an Adverse Benefit Determination we will send you a letter. The letter will explain what we decided and why we made that decision. It will have information about your appeal rights.
There will be a date on your Adverse Benefit Determination letter. If you want to file an appeal, you have to do it within 60 days of that date. There is only one level of appeal.
To file an appeal you can call Member Services. The phone number is 1-844-385-2192 (Relay 711). After you make your appeal by phone, we will need a letter from you. This will confirm that you asked for an appeal. Send your letter to Nebraska Total Care.
You can give us information to support your appeal. This can be evidence and information you think is fact or a law. You can give us information in written or in person.
Appeals for physical health and pharmacy services should be sent to:
Nebraska Total Care
2525 N 117th Ave, Suite 100
Omaha, NE 68164
You can fax the appeal to 1-844-655-0567.
Appeals for mental health or substance use services should be sent to:
Nebraska Total Care
12515-8 Research Blvd, Suite 400
Austin, TX 78759
You can fax the appeal to 1-866-714-7991.
We have an Appeal or Concern Form that you can use to file appeals. You do not have to use the form, but it may help you know what information we need. You can download and type on it before you print it. Or, you can print the form and then write in the information.
We will make a decision within 30 days. We will send you another letter with our decision.
If your medical condition is urgent, we can make a decision about your appeal much faster. You may need a fast decision if not getting the treatment will cause:
- Risk of serious health problems or death
- Serious problems with your heart, lungs, or other body parts
- You going into a hospital
Your doctor must agree that you have an urgent need. You will have a shorter time to give evidence you want us to review. We will tell you the time limits if you ask for a fast decision.
If you think you need a fast appeal decision call Member Services. The phone number is 1-844-385-2192 (Relay 711). Ask for the appeals department. Our Medical Director will make a decision and we will let you know within 72 hours.
You may disagree with an appeal decision. If that happens you may request a State Fair Hearing. This is an appeal that goes to Nebraska DHHS instead of Nebraska Total Care. In a State Fair Hearing, Nebraska DHHS will make the final decision. Your provider can only ask for a state fair hearing if you make them your authorized representative.
You must complete the Nebraska Total Care appeals process before you can request a State Fair Hearing. After we have finished your appeal, we will send you a letter. You have 120 days from the date on the letter to ask for a State Fair Hearing.
Request for a State Fair Hearing have to be in writing.
You can use the Nebraska DHHS Appeal Form to request a State Fair Hearing.
Mail your request to:
MLTC Appeal Coordinator
P.O. Box 94967
Lincoln NE 68509-4967
For more information about the State Fair Hearing process, contact Nebraska DHHS.