A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
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New Jersey General Information and Internal Plan Review: New Jersey requires you to complete 2 levels of internal appeal with your health plan prior to appealing for external appeal. The informal internal appeal can be initiated by a phone call to the health plan, by writing a letter, or by having your doctor file an appeal. You are supposed to receive a response within 5 business days or within 72 hours for an emergency. If you are still denied or restricted coverage, you may file a formal internal appeal either verbally or in writing (your health plan will provide the information you need to make this appeal). You are supposed to receive a response within 20 business days or within 72 hours for urgent or emergency care.
The External Appeal Process: Whom to contact: | New Jersey Department of Health and Senior Services, Office of Managed Care | Who can appeal: | You, your doctor, or your authorized representative | What you can appeal: | Denials, reduction, termination, or limitations of covered health care services. | When you can appeal: | After denial for coverage has been appealed through the health plan’s internal appeal process or the plan has not responded within the required deadlines, you must file within 60 days after your formal internal appeal is denied. | What to send: | A complete external appeal form (provided by your health plan) which asks for the following information: - Name and address of the health plan
- Brief description of the pertinent medical condition
- Copies of the Informal and Formal Internal Appeal denials
- Written medical records release
- Copy of your summary of insurance coverage
| What you must pay: | $25 (may be reduced to $2 in cases of financial hardship) | What will happen: | - The Department will refer your appeal to an independent utilization review organization.
- The review organization will evaluate your appeal to determine if it is acceptable.
- If your appeal is accepted for further review, you will receive a decision within 30 business days after all information needed for review has been received.
| When you will get a decision: | 30 business days after all information needed for review has been received. | In urgent situations: | If your appeal involves care for an urgent or emergency case, you will receive a response within 48 hours. |
How to Get More Information: New Jersey Department of Health and Senior Services, Office of Managed Care, 888-393-1062 (in-state only) or 609-633-0660,
www.state.nj.us/health/hcsa/hmomenu.htm Information updated as of 8-16-2004 |
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