These are the steps you can take if you have been denied covered medical benefits or want to file a complaint.
To Appeal an HMO’s Decision
Your HMO is required to have an appeal process that gives you an opportunity to resolve disagreements about denials, limitations and terminations of covered services (or benefits for such services) resulting from a decision by the HMO that the services are not medically necessary. Such decisions are adverse utilization management (UM) determinations.
Review the services covered by your HMO and the explanation of the appeal process in your evidence of coverage. You or your doctor, acting with your consent, have the right to file an appeal of an HMO’s adverse UM determination.
Inform the HMO, either verbally or in writing, that
you disagree with the HMO’s decision to deny or limit services you believe are covered and medically necessary. A different doctor at the HMO will consider your request for services. You will receive notice of whether the HMO is revising or upholding the initial decision.
If you are dissatisfied with the results of the Stage 1 appeal, you can request, either verbally or in writing, that the HMO have your appeal reviewed by a panel of doctors and other health care professionals. You will receive notice of the panel’s decision.
If you are dissatisfied with the HMO’s decision on your Stage 2 appeal, you can file an appeal with the Department of Banking and Insurance within 60 days after receiving the HMO’s Stage 2 decision. You will receive the form and instructions needed to file a Stage 3 appeal from your HMO at the same time you receive the 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 HMO.
For appeals involving urgent circumstances, the
HMO is required to respond within 72 hours in Stages 1 and 2.
To File a Complaint against an HMO
In addition to the appeal process for adverse UM determinations, you also have the right to complain to the HMO about any aspect of its operations. The HMO 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 an HMO’s business and marketing practices. The HMO is required to respond to your complaint within 30 days. The HMO’s member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the outcome of the HMO’s complaint process, contact:
NJ Department of Banking and Insurance
Division of Consumer Protection Services
Office of Managed Care
P.O. Box 329, Trenton, NJ 08625-0329
The process for appealing a decision or filing a complaint is different if you belong to a “self-funded” plan. Check with your employer or health plan and refer to Other Important Resources.
For Medicare and Medicaid managed care appeals refer to Other Important Resources.
Health Care Carrier Accountability Act
Signed into law in the summer of 2001, this legislation gives consumers covered under managed care contracts the right to sue their carrier if the consumer believes that the carrier’s decision to delay or deny care has or will result in serious harm to the consumer. In most cases, consumers will first appeal the carrier’s decision through completion of the external appeal process described above (Stage 3). However, the external appeal process can be bypassed in cases where serious harm to the consumer has already occurred or is imminent.