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.
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. Typically, a different
doctor at the plan will consider your request for
services. You will receive notice of whether the
plan is revising or upholding the initial decision.
Stage 2
If you are dissatisfied with the results of the Stage 1
appeal, 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 after 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
|
