NJDHSS

Appeals and Complaints

Steps you can 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:

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 dissatis?ed 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

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 page 19.
For Medicare and Medicaid managed care appeals refer to page 19.

Health Care Carrier Accountability Act
Signed into law in the summer of 2001, this legislation gives members consumers covered under managed care contracts the right to sue their carrier if the consumer believes that the carriers'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 HMO'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.