Written by a parent, not a doctor. Nothing here is medical advice.

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Nevada program

Outside review of a denial

An independent reviewer can reconsider certain insurance denials through Nevada’s consumer-health office.

What it is

An independent reviewer can reconsider certain insurance denials through Nevada’s consumer-health office.

A final refusal from the insurer is not always the last word. On an insured plan, Nevada's Office for Consumer Health Assistance runs the outside review. A plan where the employer pays its own claims uses a federal route instead, and a government plan follows its own; one question to HR settles which.

Eligibility rules
  • The rules apply to health carriers under NRS chapter 695G, subject to exclusions. The state employee plan incorporates them separately.
  • Private self-funded ERISA plans generally use federal review rules. Government plans need their separate statutory and plan cross-references checked.
  • External review addresses qualifying medical-necessity or experimental-treatment denials after internal appeal, or alongside it where the urgent process allows.
What you get
  • An independent decision that the covered insurer must follow.
  • An urgent-review route when the medical situation meets its test.
What the help includes
  • For ordinary statutory review, the reviewer decides within 15 days after the required information is supplied. Expedited review finishes within 48 hours after assignment. Intake and notification stages also take time. The Office confirms the applicable process and current notice deadline.
If you decide to apply
  1. Bring the denial notice to the oncology team and discuss whether outside review fits.
  2. Ask the social worker to help review the request form and medical records with the Office for Consumer Health Assistance if you choose outside review.

Office for Consumer Health Assistance: 725-281-3122 or 888-333-1597 · Official page ↗

After you ask
  • The Office has 72 hours to decide expedited eligibility, then one working day to assign a reviewer. The carrier has 24 hours to send records; the reviewer has 48 hours from assignment.
Good to know

The four months run from the day the denial arrives, so keep the letter. The social worker can help find the right route and deadline.

Other details
  • A physician may also request review. The current office number differs from an older number printed on the form.
Official sources
Ask your social worker

“Would an outside review help with a denial, and which review system covers our plan? Could the oncology team help explain urgency and the benefits or limits of that route?”

Why I’m asking: I want a denied treatment reviewed by the right decision-maker.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

File within four months of the denial and say if it is urgent.

Your social worker

The oncology team writes why the treatment is needed and sends the records.

The care team

A physician can file the request as well as the parent.

Who decides
An independent review organisation, assigned by the Office for Consumer Health Assistance.
Ask the agency
“I want an external review of this denial, and my child's oncologist says it is urgent. Please open the expedited track.”

How to apply

First step: Call the Office for Consumer Health Assistance on 725-281-3122 or 888-333-1597 and ask for the external review form.

  1. Get the denial in writing and note the date on it.
  2. Ask the oncologist for a letter saying why the treatment is needed now.
  3. Call the Office for Consumer Health Assistance on 725-281-3122 and ask for the expedited track if it is urgent.

Official application / program page ↗

Where it starts: File the external review request form with the Office for Consumer Health Assistance.

What to gather

The diagnosis letter, the child’s insurance card, and the last two pay stubs cover most applications. The official page lists the rest.

How long: 15 days for an ordinary review. Expedited: 72 hours to decide the request, one working day to assign, 24 hours for the plan's documents, 48 hours to finish.

Clock: You have four months from the adverse-determination notice to ask for an external review.

What a yes looks like

A written decision from the independent reviewer that the plan must follow.

What a no looks like, and the next move

A decision upholding the plan, or a refusal on eligibility. Ask which exclusion was used.

Watch out

  • The four-month clock runs from the denial notice.
  • The Office's current number is 725-281-3122; the review form still prints an older number.
  • An employer self-funded plan follows federal rules instead. Ask human resources which kind yours is.

If they say no, quote this: NRS 695G: four months from the notice of adverse determination to request external review.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

An independent doctor reviews the denial. Four months to ask, 15 days for an ordinary answer, 48 hours when it is urgent.

  • $4 — Months to request an external review
  • $15 — Days for an ordinary independent review decision
  • $72 — Hours for the Office to decide an expedited request
  • $48 — Hours for the reviewer to finish an expedited review

Legal protection: An independent review organisation decides, not the plan · A separate expedited track with its own short clocks

What it costs the family: None.

The eligibility facts, as published

Plans
health carriers subject to NRS chapter 695G, with the stated exclusions; the state employee plan incorporates the rules by statute
Timing
four months from the adverse-determination notice
Self funded
an employer self-funded plan follows federal rules instead

The trap: The four-month clock runs from the denial notice. It is the one deadline on this page that is easy to lose while you are in hospital.

Where I read this

← Back to your options