What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. Nebraska-only details below.
Confirm plan type: Nebraska: Start Here.
Nebraska PA rules
Nebraska's Ensuring Transparency in Prior Authorization Act (LB 77, operative January 1, 2026) is in Neb. Rev. Stat. §§ 44-5433–44-5444 . It applies to most fully insured commercial plans—not self-funded ERISA plans unless they opt in.
Decision deadlines
- Non-urgent: notify patient and provider within 7 days after the utilization review agent has all information needed ( § 44-5438 )
- Urgent: within 72 hours (reduced to 48 hours starting January 1, 2028)
- If the agent misses these deadlines, the service is deemed authorized (§ 44-5438)
Transparency & denials
- PA rules and clinical criteria must be posted online; new rules need 60 days' provider notice before taking effect (§ 44-5434)
- Adverse PA determinations must be made by a physician (or appropriate clinical peer); you may request peer-to-peer discussion within 3 business days of a medical-necessity denial (§ 44-5435)
- PA appeals must be reviewed by a physician in the same or similar specialty who did not make the original denial (§ 44-5436)
- Denials cannot be based solely on artificial intelligence; AI use must be disclosed (§ 44-5443)
Standard forms
Starting January 1, 2026, providers must use NDOI-approved two-page uniform PA forms for drugs/DME and for other services (§ 44-5437). Forms and guidance: NDOI guidance documents.
What plans cannot require PA for
- Emergency room care and emergency ground ambulance transport
- USPSTF "A" or "B" preventive services, ACIP immunizations, and certain women's preventive services (§ 44-5439)
After approval
- Approved PA generally valid up to one year; prior insurer approvals honored at least 60 days after a plan change when documented (§§ 44-5441–44-5442)
- Agent cannot revoke an approval if care occurs within 60 days of provider receipt of approval unless eligibility changed (§ 44-5440)
Where to look up PA rules
Carriers must publish PA criteria on their websites. Use your denial letter first, then your plan's provider or member portal.
Carrier links: Nebraska prior auth & internal appeals links.
Medicaid
Heritage Health managed care follows federal Medicaid prior authorization and appeal rules, with some LB 77 provisions (such as biomarker testing) applying to Medicaid where implemented. Denials use MCO grievance and DHHS fair hearing paths—see Nebraska internal appeals.
If PA is denied
Request the clinical rationale and file an internal appeal within 180 days. PA-specific appeals under LB 77 must be physician-reviewed (§ 44-5436).
Next: Nebraska internal appeals.
Urgent care
Mark the request urgent when waiting for a standard decision would seriously jeopardize life, health, or ability to regain maximum function. Nebraska requires a 72-hour PA decision for urgent requests (48 hours from 2028).
You may also request an expedited internal appeal and, in urgent situations, may request external review at the same time as your internal appeal (NDOI — appeals steps).