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Independent Health Care Appeals Program

The Independent Health Care Appeals Program (IHCAP) is an external review program administered by the Department of Banking and Insurance (Department). The external review program is intended for the purpose of reviewing adverse utilization management determinations made by carriers with respect to any health benefits plan for which the carrier uses utilization management features, whether prospective, concurrent, or retrospective.

The Department contracts through the State of New Jersey procurement process with multiple Independent Utilization Review Organizations (IURO) to perform both the preliminary and full reviews of the cases presented to the IHCAP. The cost of reviews is fixed through the procurement process. Carriers bear the costs of both the preliminary and full review, and once a preliminary or full review is initiated, the carrier is responsible for the associated costs of that portion of the review, even if the carrier elects to reverse its own decision prior to the IURO rendering a decision on the matter, or the individual, or health care provider, as appropriate, elects to withdraw the appeal.

The Department performs a cursory review of requests submitted for the IHCAP. The Department will not forward an appeal to an IURO if it is clear that:

For more information...
Appeal and Complaint Guide for New Jersey Consumers Appeal and Complaint Guide for New Jersey Consumers
  1. The individual is covered under a self-funded welfare plan, Medicare, or a Medicare Advantage product;
  2. The individual is covered under a contract delivered in another state;
  3. The services at issue were not covered under the terms of the health benefits plan;
  4. When the appeal is submitted by a health care provider, the health care provider lacked consent of the covered individual to make the appeal;
  5. The filing fee is not included; or
  6. The internal appeal process has not been completed, unless the carrier failed to meet the timeframes for the separate stages of appeal, waived its right to perform an internal review, or the individual and/or provider applied for an expedited external review at the same time as applying for an expedited internal review.

The Department may consult with the individual or the health care provider, as appropriate, to try to obtain more information when reasonable or appropriate.

Cases forwarded by the Department are assigned to the IUROs on a random basis, except as may be necessary to avoid any actual or perceived conflicts of interests.

Preliminary Review
Upon receipt of the appeal from the Department, the IURO will conduct a preliminary review of the appeal, and accept it for processing if it determines that:
  1. The individual had coverage in effect under a health benefits plan at the time of the action on which the appeal is based;
  2. The service that is the subject of the complaint or appeal reasonably appears to be a covered service under the terms of the contract at issue for purposes of the appeal;
  3. The internal appeal process was appropriately completed, or approval to by-pass some portion of the process was received by the Department; and
  4. The individual, or health care provider acting on behalf of the individual with the individual's consent, has provided all information required by the IURO and the Department to make the preliminary determination, including: the appeal form (or Medicaid version), a copy of any information provided by the carrier regarding the unfavorable utilization management determination, and a fully-executed release to obtain any necessary medical records from the carrier and any relevant health care provider. (The medical release is included in the Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims or the IHCAP appeal form (or Medicaid version.)

The IURO will complete the preliminary review and notify the individual and/or health care provider, as appropriate, in writing of whether the appeal has been accepted for processing within 5 business days of receipt of the request from the Department. If the appeal is not accepted, the reason(s) why it was not accepted will be included in the written notice. The IURO shall additionally notify the individual and/or provider of his or her right to submit in writing, within five (5) business days of the receipt of acceptance of the appeal, any additional information to be considered in the IURO's review.
Full Review

If, after the preliminary review, the appeal appears acceptable, the IURO will conduct a "full review" to determine whether an individual has been inappropriately denied medically necessary covered services by the carrier. When performing the full review, the IURO relies on all information submitted by the parties to the matter that is deemed appropriate by the IURO, including: pertinent medical records, consulting physician reports, and similar such documents submitted by the parties; any applicable, generally- accepted practice guidelines developed by the federal government, and national or professional medical societies, boards and associations; and, any applicable clinical protcols and/or practice guidelines developed or used by the carrier. The IUROs typically use consultant medical professionals to review cases, but all decisions must be approved by an IURO's medical director.

The IURO may uphold, reverse or modify the utilization management decision of the carrier. A modification means that the IURO upholds a portion of the carrier's utilization management decision, and reverses a portion of it. The IURO cannot recommend that services other than those at issue in the appeal be provided.

The written decision of the IURO, and the reasons for the decision, is sent to the covered individual and/or health care provider, as appropriate, as well as to the carrier, and to the Department. The IURO's decision is binding on the covered individual and carrier, except to the extent that other remedies are available to either party under State or Federal law.

Before You Mail Your Appeal to the Independent Health Care Appeals Program:
  • Attach the filing fee of $25.00. Make the Check or Money Order payable to "New Jersey Department of Banking and Insurance." Send a check or money order only. DO NOT SEND CASH! (Note: The filing fee will be waived if you submit evidence of participation in one of the following: Pharmaceutical Assistance to the Aged and Disabled, Medicaid, NJ FamilyCare, General Assistance, SSI, or New Jersey Unemployment Assistance.)
  • Attach a copy of the Stage 1 and/or Stage 2 written decision from the carrier.
  • Attach a copy of the summary of coverage from your member handbook, certificate of coverage or other evidence of coverage issued by your carrier.
  • If a health care provider filing on behalf of a member, attach a copy of the member's consent to have an appeal of the adverse utilization management decision made on his or her behalf. Whenever possible, please use Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims.
  • Attach a copy of all medical records and correspondence to be reviewed by the Independent Health Care Appeals Program.

    Send only copies of any requested documents, because originals WILL NOT be returned.
Confidentiality and Semi-Annual Reports

The information related to, and the outcome of, any specific case is confidential, and is not subject to release by the IURO or the Department. However, the Department does produce a semi-annual report regarding the activities of the IHCAP for a six-month period, typically ending in February and August.

The Independent Health Care Appeals Reports, generated for the Legislature and Governor, are posted as they become available for release. The information contained in the semi-annual reports never identifies any individual, nor any details about any specific case. The information is presented in the aggregate, and provides information about the number of appeals processed, and the number of appeals upheld and reversed.
OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.
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