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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
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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.
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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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