Appeals and Complaints
Steps to take if you have been denied covered medical benefits or want to file a complaint.
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:
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 resolution reached through 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 Dept. of Health and Senior Services
For complaints about business practices such as claims payment, member enrollment or termination of coverage:
NJ Dept. of Banking and Insurance
Note: The process for appealing a decision or filing a complaint is different if you belong to a "self-insured" plan. Check with your employer or health plan and refer to Contacting Your Health Plan.