Appeals Form

You have a right to appeal if you think Nevada Health Link (NVHL) made a mistake about:

Initial or redetermination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions;
Failure by the Exchange to provide timely notice of an eligibility determination;
Denial of a request to vacate dismissal made by the Exchange’s appeals entity, and
An appeal decision issued by the Exchange’s appeals entity

Instructions

You have ninety (90) days from the date on your Eligibility Notice to file an appeal. The date of the postmark on your appeal envelope or the date your email is received is considered the date you filed your appeal.

Your Eligibility Notice explains whether you qualify for financial assistance to purchase insurance on Nevada Health Link. Depending on your eligibility results, you may appeal.

To mail in your appeal request please print and fill out the Nevada Health Link Appeal Form (Keep a copy of your reference).
- Mail to:
  Nevada Health Link
  Appeals Department
  2310 S. Carson Street, Suite 2
  Carson City, NV 89701
- To file an appeal over the phone call:
  Nevada Health Link Call Center
  1-800-547-2927

Or fill out the online form below.

Do you need assistance completing this appeals request?

You can choose an authorized representative.

You can give a trusted person permission to communicate about this appeal with us, see your information, and act for you on matters related to this appeal, including getting information about your appeal and signing your appeal on your behalf. This person is called an “authorized representative.” If you do not already have an authorized representative, you can find the form and submit with your supporting documentation below.

Requesting an Expedited Appeal

In the event that a standard appeal could jeopardize an applicant’s life, health, or ability to attain, maintain, or regain maximum function you may request an expedited appeal. While completing the form below in the explain the reason for your appeal section please explicitly request an expedited appeal with a brief explanation as to how you meet the criteria for one.

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Eligibility Determination Being Appealed*
Month
Day
Year
Reason for Appeal*
- NVHL Enrollment Eligibility
- Special Enrollment Period
- APTC/CSR Eligibility or Amount
- Failure of Timely Eligibility Notification by NVHL
Explain the Reason for Your Appeal*
Your explanation should state the reason for your appeal, including relevant dates and account history. List any actions or communications you attempted to resolve your request prior to the appeal. Please provide additional documentation such as notices received. If your appeal request affects or impacts other members of your household, note their names and how they are impacted here.
Expedited Appeal Request
- Request Expedited Processing
You must explain how your life, health, and/or normal functioning are in immediate jeopardy in order for this to be considered for expedition.
Explain the Reason for Expedited Request (If marked above)
Your explanation should clearly convey how your life, health, or normal functioning are in immediate jeopardy by normal appeal processing.
Supporting Documentation
Drop files here or

Accepted file types: jpg, gif, pdf, png, Max. file size: 100 MB.
You may submit additional information to support your appeal. Information you submit will be reviewed along with the information you submitted previously. You may submit additional information in advance of your appeal hearing by attaching and returning it with this form or by mailing it separately to: Nevada Health Link Attn: Appeals 2310 S. Carson St. Suite. 2 Carson City, NV 89701 If you mail additional information separately, include the complete contact information of Claimant (as it appears on this form), including name, date of birth, phone number, email address (optional), and address. Additional information may also be submitted at the time of the appeal hearing.
E-Signature*
First Last
The information in this section applies to all people signing above, including the Claimant. I further understand that by completing, signing, and dating below, I authorize Nevada Health Link to disclose information collected based on my application and from other data sources that may have been used to make the eligibility determination. I understand that this information may be disclosed for use during the appeals process. The authorization is valid until the appeal is concluded or I notify Nevada Health Link otherwise. I understand by completing, signing, and dating above, I authorize Nevada Health Link to disclose information in my eligibility record, based on the application I filled out, and from other data sources that may have been used to make the eligibility determination, to my authorized representative and other household members whose signatures are provided below. I understand I may request a copy of my eligibility record during the appeals process. The authorization is valid until the appeal is concluded or I notify you otherwise. I am signing this form under penalty of perjury, which means I have provided true answers to all the questions I have answered to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I provide false information. I understand that I am not required to complete this form. I am voluntarily completing it to file an appeal request to Nevada Health Link. I understand that I am the primary contact for purposes of appealing these eligibility determinations.
Date*
MM slash DD slash YYYY
CAPTCHA

Notice of Privacy Practices

Nevada Health Link is committed to maintaining the privacy and security of personally identifiable information. Nevada Health Link will use personally identifiable information only as permitted by Nevada Health Link’s policies and as required by law.

More information about Nevada Health Link’s privacy and security practices and your rights is available on Nevada Health Link’s website at Nevada Health Link’s Privacy Policy

If you need help understanding this form in another language, or if you are disabled and need help to use this form, please contact Nevada Health Link. There is no cost for assistance.

Note: Healthcare.gov will be processing requests for exemptions. For more information please visit https://www.healthcare.gov/health-coverage-exemptions/

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