To Appeal a Health Plan Decision
Your plan is required to have an appeal process that gives you an opportunity
to resolve disagreements about denial of a covered benefit:
Preliminary Stage
Review the services covered by your plan and the explanation of the appeal
process in the plan’s member handbook. You or your doctor, acting
with your consent, have the right to file an appeal.
Stage 1
Inform the plan, either verbally or in writing, that you disagree with
the plan’s decision to deny or limit services you believe are covered.
Stage 2
If you are dissatisfied with the results of the initial communication
with the plan, you can request, either verbally or in writing, that the
plan have your appeal reviewed by a panel of doctors and other health
care professionals.
Stage 3
If you are dissatisfied with the plan’s decision on your Stage
2 appeal, you can file an appeal with the Department of Health and Senior
Services within 60 days of receiving the plan’s Stage 2 decision.
You will receive the form and instructions needed to file a Stage 3 appeal
from your health plan at the same time you receive the plan’s Stage
2 appeal decision. Your case will be reviewed by independent experts
under contract to the State through the Independent Health Care Appeals
Program (IHCAP). Decisions made by the IHCAP are binding on the health
plans.
For appeals involving urgent circumstances, the plan is required to
respond within 72 hours in Stages 1 and 2.
To File a Health Plan Complaint
In addition to the appeal process for denial of a covered benefit, you
also have the right to complain to the health plan about any aspect of
its operations. Your plan is required to have a system to resolve complaints
about such things as quality of medical care, choice of doctors and other
health care providers, and difficulties with processing claims or disputes
about a plan’s business and marketing practices. The plan is required
to respond to your complaint within 30 days. The plan’s member handbook
contains a description of the process and
contact information for resolving complaints. If you are dissatisfied
with the outcome of the plan’s complaint process, contact the appropriate
State agency:
For complaints about quality of care, choice of providers or access
to network providers:
NJ Department of Health and Senior Services
Office of Managed Care
P.O. Box 360
Trenton, NJ 08625-0360
(888) 393-1062
www.state.nj.us/health/hcsa/hmocompl.pdf.
For complaints about business practices such as claims payment, member
enrollment or termination of coverage:
NJ Department of Banking and Insurance
Division of Enforcement and Consumer Protection
P.O. Box 329
Trenton, NJ 08625-0329
(800) 446-7467
www.state.nj.us/dobi/enfcon.htm
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