Appealing Unfavorable Medical Necessity Decisions
The SEH Program health benefits plans permit carriers to consider whether many of the services covered under the contract or policy are medically necessary and appropriate for purposes of treatment of the covered person’s condition. If a carrier determines that a service is not medically necessary and appropriate (including determinations that the service is experimental or investigational, cosmetic, or dental instead of medical), the covered employee or dependent has the right to appeal the unfavorable determination.
In New Jersey, carriers are required to have a two-stage internal appeal process. In addition, if the outcome continues to be unfavorable and the employee or dependent continues to disagree, the appeal may be taken to an external independent utilization review organization through the Independent Health Care Appeals Program, which is under the auspices of the New Jersey Department of Banking and Insurance.
The covered employee or dependent may authorize a health care provider to make the appeals on behalf of the covered employee or dependent by providing written consent. The small employer does not have to become involved with either the internal or external appeal process.
The New Jersey Department of Banking and Insurance has a more detailed discussion of the right to appeal medical necessity determinations both internally and through the Independent Health Care Appeals Program on the Department’s web site.