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Home > Insurance Division > Life and Health > Life & Health Actuarial > HMO and PPO Performance Report
2014 New Jersey HMO and PPO Performance Report
Appeals and Complaints

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 or PPO's Decision

Your HMO or PPO 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 or PPO that the services are not medically necessary. Such decisions are adverse utilization management (UM) determinations.

Review the services covered by your HMO or PPO and the explanation of the appeal process in your evidence of coverage or member handbook. You or your doctor, acting with your consent, have the right to file an appeal of an HMO’s or PPO's adverse UM determination.

Stage 1

Inform the HMO or PPO in writing that you disagree with the carrier's decision to deny or limit services you believe are covered and medically necessary. Typically, a different doctor at the HMO or PPO will consider your request for services. You will receive notice of whether the HMO or PPO is revising or upholding the initial decision.

Stage 2

If you are dissatisfied with the results of the Stage 1 appeal, you can request in writing, that the HMO or PPO have your appeal reviewed by a panel of doctors and other health care professionals. You will receive notice of the panel’s decision. Consumers enrolled in an individual health benefits plan do not have to file a Stage 2 appeal and may proceed directly to Stage 3 appeal.

Stage 3

If you are dissatisfied with the carrier's decision on your Stage 2 appeal, you can file an appeal with the Department of Banking and Insurance within four months after receiving the carrier's Stage 2 decision, or if you are enrolled in an individual health benefits plan you can file within four months of receiving the carrier's Stage 1 appeal decision. You will receive the form and instructions needed to file a Stage 3 appeal from your HMO or PPO at the same time you receive the Stage 2 appeal decision, or the Stage 1 appeal decision if you are enrolled in an individual health benefits plan. Your case will be reviewed by independent experts under contract with the State through the Independent Health Care Appeals Program (IHCAP). Decisions made by the IHCAP are binding on the HMO or PPO and the covered person, except to the extent that other remedies are available to either party under State or Federal law.

For appeals involving urgent circumstances, the HMO or PPO is required to respond within 72 hours at Stages 1 and 2 of the appeal process.

To File a Complaint against an HMO or PPO

In addition to the appeal process for adverse UM determinations, you also have the right to complain to the HMO or PPO about any aspect of its operations. The carrier 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 carrier's
business and marketing practices. The HMO or PPO is required to respond to your complaint within 30 days. Your evidence of coverage or member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the outcome of the carrier's complaint process, contact: 

NJ Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 329, Trenton, NJ 08625-0329
(888) 393-1062
www.state.nj.us/dobi/division_insurance/managedcare/

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.

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New Jersey Department of Banking and Insurance