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Managed Care Complaints, Frequently Asked Questions and Definitions
How to File a Managed Care Complaint


Every person covered under a managed care plan has the right to file a complaint with his carrier about any aspect of the coverage, the carrier's network, and the services provided by health care providers. If the individual prefers, he may have his health care provider file the complaint instead, if the individual gives consent, and the health care provider agrees to do so.

A carrier is required to respond to complaints filed by or on behalf of its covered individual within a reasonable period of time up to 30 days after the date the carrier received the complaint. Carriers are required to establish a complaint system, and to provide covered individuals a written explanation about the process for filing a complaint. Generally, this information will be contained in a member handbook or certificate of coverage, but it may be provided separately. The information should include the telephone number and address of the carrier's offices responsible for complaint resolution. In addition, the information must advise covered individuals of their right to contact the New Jersey Department of Banking and Insurance (Department), in the event that the covered individual is not satisfied with how the carrier handled the complaint.

The Department has an office within Consumer Protection Services that handles complaints from consumers and health care providers regarding coverage and/or payment under a managed care plan, including: complaints primarily concerning quality of care, choice and accessibility of health care providers, issues relating to the adequacy of the carrier's networks, and claims payment practices. The Department also addresses complaints regarding marketing practices, and policy provisions, but these complaints may be handled by a different office within Consumer Protection Services.

An individual wishing to file a complaint may submit the complaint form (PDF or MS Word) by mail to:

Office of Managed Care
Consumer Protection Services
Department of Banking and Insurance
P.O. Box 329
Trenton, NJ 08625-0329

Fax: (609) 633-0807
Telephone: 1-888-393-1062

In addition to filing a complaint, an individual who disagrees with the decision of her carrier to deny, terminate or limit her access to a covered service, or benefits for that service, has the right to appeal that decision, first internally with the carrier, and finally externally with the Independent Health Care Appeal Program (IHCAP) if not satisfied with the outcome of the internal appeals. For more information on this process, please see How to File a Utilization Management Determination.

If a health care provider has a specific complaint about how a claim is being handled, the health care provider may file a claims payment appeal with the carrier in an effort to resolve the situation.  A health care provider must file the appeal within 90 days following a claims determination.  The health care provider may take the matter to New Jersey Program for Independent Claims Payment Arbitration (PICPA) if necessary, and if the claim(s) involve $1,000 or more, but ONLY if the health care provider submitted the claim to the carrier’s internal claims payment appeal process first.  Health care providers may aggregate claims to reach the arbitration threshold. 

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Managed Care Frequently Asked Questions (FAQs)
Questions regarding Health Maintenance Organizations (HMOs)
Where can I obtain information about a Medicare HMO?
 
You may obtain further information about Medicare HMOs in New Jersey by contacting the New Jersey Department of Health & Senior Services State Health Insurance Assistance Program (SHIP) at 1-800-792-8820. You could also contact the Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE, or via the internet at www.medicare.gov.
Can my HMO exclude coverage for a pre-existing condition?
 

For a large group contract (employers with more than fifty employees), a pre-existing condition exclusion is permitted only if the exclusion relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the six month period prior to enrollment. The exclusion period must not exceed twelve months (eighteen months for late enrollees). The exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date. A pre-existing condition exclusion may not be imposed on newborns, adopted children or children placed for adoption under certain circumstances. Pregnancy may not be considered as a pre-existing condition. In the small employer market (employers with two to fifty employees), a pre-existing condition exclusion period is permitted only for groups of two to five employees and for "late enrollees," that is, an employee or dependent who fails to enroll for coverage within thirty days of being offered coverage. Further, for groups of two to five employees and late enrollees, a pre-existing condition exclusion period is permitted only if the exclusion relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the six month period prior to enrollment. Pregnancy may not be considered as a pre-existing condition. The exclusion period may not exceed six months. The exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date so long as replacement coverage is obtained within ninety days of the termination of the prior coverage.

For individual contracts (for individuals and their families), a pre-existing condition exclusion is defined more broadly than in the small and large employer markets and also includes a condition for which a reasonable person would have sought treatment even if treatment was not recommended or received. Further, pregnancy may be considered a pre-existing condition. The exclusion period for a pre-existing condition may not exceed twelve months, and the exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date so long as replacement coverage is obtained within 31 days of the termination of the prior coverage, or 63 days if the person had 18 months of continuous group coverage and has exhausted any continuation rights under the group plan.

 
Questions regarding Workers' Compensation Managed Care Organizations (WCMCOs)
How is the premium discount obtained when offering a managed care arrangement in the workers' compensation market?
 
The insurance carrier applies for the discount by identifying the approved Workers' Compensation Managed Care Organization (WCMCO) they are contracting with. For additional information about filing for a worker's compensation premium discount, insurers should contact the Compensation, Rating, and Inspection Bureau (CRIB) at (973) 622-6014. Employers should ask their Workers Compensation insurer what managed care programs and discounts are available.
Do utilization review companies and case management companies require a license in order to contract with a Worker's Compensation Managed Care Organization (WCMCO) or any other entity?
 
At this time, there are no regulations which license utilization review companies or case management companies. The WCMCO regulations specify the requirements for utilization review and case management when applied to worker's compensation cases.
 
Questions regarding Selective Contracting Arrangements (SCAs)
Does an insurer have to file rates for an SCA?
 
Large group rates are not filed for an SCA. Small group rates are filed with the Department of Banking and Insurance, for review.
 
Questions regarding Dental Plan Organizations (DPOs)
How long does a DPO have to address a written complaint?
 
Pursuant to the DPO Regulations at N.J.A.C. 11:10-1.10, a DPO must respond to a written complaint within (15) working days of receipt of the complaint.
When is the DPO renewal application due?
 
The annual renewal application is due in our office no later than sixty (60) days prior to the date of expiration of the current Certificate of Authority (COA). Failure to remit the renewal application may result in a fine or suspension or revocation of the COA.
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Managed Care Definitions and Acronyms
ACTIVE HMO
A Health Maintenance Organization with a Certificate of Authority to transact business in New Jersey that is marketing to prospective Members.
ADMINISTRATIVE
SERVICES ONLY (ASO)
An arrangement whereby an employer uses the provider network of an HMO, PPO or TPA on a fee-for-service basis, but the HMO, PPO or TPA itself only provides, and is reimbursed for, administrative services; or, where a payor (employer, union, etc.) uses a TPA or carrier to administer a health care program.
ADMITTED ASSETS
Those assets of a carrier that are acceptable for purposes of statutory financial reporting to a governmental agency.
AFDC
Aid to Families with Dependent Children, established by 42 USC 601 et seq., and N.J.S.A. 44:10-1 et seq., as a joint Federal/State cash assistance program administered by counties under State supervision
ALLOWABLE EXPENSE
See usual, customary and reasonable (UCR) charge.
BALANCE BILLING
The practice whereby a covered person is billed for the difference between the provider's billed charge and the carrier's UCR charge.
BASIC COMPREHENSIVE
HEALTH CARE SERVICES
Preventive care, emergency care, inpatient and outpatient hospital and provider care, diagnostic laboratory and diagnostic and therapeutic radiological services and other services, as set forth in N.J.A.C. 11:24-5.
CAPITATION
A fixed payment, for a specified time period, for the provision of health care services or supplies, not based on frequency or severity of services or supplies provided.
CARRIER
An insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue Health Benefit Plans in New Jersey. [In some laws, may also include a dental plan organization (DPO) and/or dental service corporation (DSC).]
CMS
The Center for Medicare and Medicaid Services (formerly HCFA, the Health Care Financing Association) within the U.S. Department of Health and Human Services.
CERTIFICATE OF AUTHORITY (COA)
A license granted by DOBI to operate an HMO or health service corporation, or to operate a DPO or a DSC, in New Jersey.
CLEAN CLAIM
A claim that has no defect or impropriety, including any lack of required substantiating documentation, or particular circumstance requiring special treatment that otherwise prevents timely payment being made on the claim.
COMPENSATION RATING AND INSPECTION BUREAU (CRIB)
The Bureau created, organized and supervised by the Commissioner of DOBI in accordance with N.J.S.A. 34:15-1 et seq., the New Jersey Workers' Compensation Law.
COMPREHENSIVE HEALTH CARE SERVICES
Basic benefits provided under a health benefits plan, including medical and surgical services provided by licensed health care providers who may include, but are not limited to, family physicians, internists, cardiologists, psychiatrists, rheumatologists, dermatologists, orthopedists, obstetricians, gynecologists, neurologists, endocrinologists, radiologists, nephrologists, emergency services physicians, ophthalmologists, pediatricians, pathologists, general surgeons, osteopathic physicians, physical therapists and chiropractors. Basic benefits may also include inpatient or outpatient services rendered at a licensed hospital, covered services performed at an ambulatory surgical facility and ambulance service

CONTESTED CLAIM

A claim that has not been adjudicated because it has a material defect or impropriety.

COINSURANCE
Percentage of a covered charge that must be paid by the person covered under a health benefits plan (HBP). Coinsurance does not include deductibles, copayments or non-covered charges.
COPAYMENT
Direct payment that a covered person must make to a participating provider in order to receive a covered health care service or supply.
COVERED PERSON
A person who is eligible for services or benefits through a HBP.
DEDUCTIBLE
Dollar amount that must be paid to providers by a covered person in a HBP before the Plan will begin paying for covered services or supplies.
DENTAL PLAN ORGANIZATION (DPO)
Any person or company who provides directly or arranges to administer one or more plans providing dental services that are on a prepaid or postpaid individual or group capitation basis. The covered person is eligible to receive treatment from in-network dentists only (except in the case of an emergency over 50 miles from home). The covered person may be required to pay a deductible or copayment for treatment, but no balance billing is allowed.
DENTAL SERVICE
CORPORATION (DSC)
A corporation which is organized, without capital stock, and not for profit, for the purpose of establishing, maintaining and operating a nonprofit dental service plan. The expense of dental services to covered persons is paid in whole or in part by the corporation to participating dentists on a fee for service basis in return for premium or other valuable considerations. The covered person is eligible to receive treatment from in-network dentists only. The enrollee may be required to pay a deductible and copayment depending on the plan.
DHS

New Jersey Department of Human Services.

DHS PROGRAMS
Medical assistance programs (Medicaid, NJ Kidcare and NJ FamilyCare) that are administered by the DHS.
DHSS
New Jersey Department of Health and Senior Services.
DOBI
New Jersey Department of Banking and Insurance.
HEALTH BENEFITS
PLAN (HBP)

A benefits plan which pays for or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this state by or through a carrier. HBP includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. HBP shall not include the following plans, policies or contracts: accident only, credit, disability, long term care, CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection issued pursuant to N.J.S.A. 39:6A-1 et seq., or hospital confinement indemnity coverage.

HEALTH
MAINTENANCE
ORGANIZATION (HMO)

Any organization which directly or through contracts with providers furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographic area.

INACTIVE HMO

An HMO with a COA to transact business in New Jersey that is no longer marketing to prospective members.

INDEMNITY HEALTH
INSURANCE PLAN
A type of Health Benefits Plan that reimburses the insured for amounts paid for health care services and supplies, subject to UCR charges and deductible and coinsurance provisions. This type of plan does not require the use of particular providers, or provide different benefits depending on the provider chosen.
INDEPENDENT PRACTICE
ASSOCIATION (IPA)

Association of individual physicians that provides services on a negotiated capitation rate, fee-for-services basis, or flat retainer fee.

LIMITED HEALTH CARE SERVICES
A health service or benefit which a carrier has elected to subcontract for as a separate service, which may include, but shall not be limited to, substance abuse services, vision care services, mental health services, podiatric care services, chiropractic services or rehabilitation services. Limited health care services shall not include pharmaceutical services, case management services or employee assistance plan services.
LIQUID ASSETS
Cash, cash equivalents or investments as set forth at N.J.S.A. 17B:20-1a. This includes the following items on an HMO's financial statement: cash, investment income receivable, amounts due from affiliates, stocks & bonds, restricted assets and other current assets.
MANAGED CARE PLAN (MCP)

A health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangement with participating providers, who are selected to participate on the basis of explicit standards, to furnish a specified set of health care services, and includes financial incentives for covered persons to use participating providers.

MEDICAID
The joint federal/state program of medical assistance established by Title XIX of the Social Security Act, 42 U.S.C. 1396 et. seq., which in New Jersey is administered by the Division of Medical Assistance and Health Services in the Department of Human Services pursuant to N.J.S.A. 30:4D-1 et. seq.
MEDICAL LOSS RATIO (MLR)
The cost for the direct provision of medical services and supplies divided by the premiums charged to provide those medical services and supplies.
MEDICARE
Federally sponsored program under the Social Security Act that provides hospital benefits and supplementary medical care to most persons 65 years of age and older and some persons who qualify due to disability or end stage renal disease.
NJ KIDCARE

A program of DHS which provides free or subsidized HMO Medicaid-level coverage for children in low income families who would not ordinarily be eligible for Medicaid coverage because the family income limit for Medicaid is exceeded.

NJ FAMILYCARE
A program of DHS which provides free or subsidized HMO Medicaid-level coverage for low income adults who would not ordinarily be eligible for Medicaid coverage because the family income limit for Medicaid is exceeded
OPEN ACCESS
A feature of a Managed Care Plan that allows members to access care from a participating specialist provider for all or stated services without a referral from a Primary Care Provider.

OPEN AND UNREPORTED
RESERVES (O&U)

The estimate of liability for incurred but unpaid medical claims at a given point in time. It includes both open claims (reported but not yet paid) and an estimate of IBNR (incurred but not reported) claims at that point in time.

ORGANIZED DELIVERY SYSTEM (ODS)
An organization with defined governance that:
(a) is organized for the purpose of and has the capability of contracting with a carrier to provide, or arrange to provide, under its own management substantially all or a substantial portion of the comprehensive health care services or benefits under the carrier's benefits plan on behalf of the carrier, which may or may not include the payment of hospital and ancillary benefits; or
(b) is organized for the purpose of acting on behalf of a carrier to provide, or arrange to provide, limited health care services that the carrier elects to subcontract for as a separate category of benefits and services apart from its delivery of benefits under its comprehensive benefits plan, which limited services are provided on a separate contractual basis and under different terms and conditions than those governing the delivery of benefits and services under the carrier's comprehensive benefits plan.
An ODS shall not include an entity otherwise authorized or licensed in this State to provide comprehensive or limited health care services on a prepayment or other basis in connection with a health benefits plan or a carrier.
PARTICIPATING PROVIDER
A Provider who, under contract or other arrangement with a Managed Care Plan, has agreed to provide health care services or supplies to covered persons with an expectation of receiving payment from the Plan and (usually) a Copayment from the covered person.
POINT OF SERVICE
(POS) CONTRACT

A contract that provides coverage for the services of network providers subject to the applicable copayment, as well as coverage for the services of non-network providers subject to the UCR charge and the deducible and coinsurance provisions of the contract.

PREFERRED PROVIDER
ORGANIZATION (PPO)
A group of hospitals, physicians, and/or other providers who have contracts with a carrier, employer, third-party administrator, or other payor to provide health care services to covered persons at negotiated rates.
PROVIDER
Any physician, hospital, or other person or facility licensed or otherwise authorized to provide health care services or supplies in the state or jurisdiction in which they are furnished.
PRIMARY CARE
PROVIDER (PCP)
An individual participating provider who supervises, coordinates and provides initial and basic care to HMO members, maintains continuity of care for the members, and who satisfies the qualifications stated at N.J.A.C. 11:24-6.2.
QUALITY ASSURANCE
A system-wide continuous quality improvement program to monitor the availability, accessibility, continuity, and appropriateness of services provided to covered persons in a HBP.
SELECTIVE CONTRACTING
ARRANGEMENT (SCA)

An arrangement for the payment of predetermined fees or reimbursement levels for covered services by the carrier to Preferred Providers or Preferred Provider Organizations.

SELF-FUNDED HEALTH
PLAN
A plan offered by an employer whereby health claims are funded by the employer, generally using a Third Party Administrator (TPA), in lieu of premium paid to a carrier. State law consumer protections generally do not apply to such an arrangement.
STOP-LOSS INSURANCE

Protection purchased from an insurance company by a carrier, or an employer using a Self-Funded Health Plan, against the risk of large losses or severe adverse claim experience.

THIRD PARTY
ADMINISTRATOR (TPA)
An entity that performs administrative functions (such as claims processing), on behalf of a Health Benefits Plan or a Self-funded Health Plan.
USUAL, CUSTOMARY AND REASONABLE (UCR) CHARGE
The amount, as determined by the carrier or by an independent data collection agency, that is most often charged for a specified service or supply by providers within the same geographic area. UCR applies to services and supplies only when a non-network provider is used; the negotiated fee applies when network providers are used.

UTILIZATION
MANAGEMENT (UM)

A system for reviewing the appropriate and efficient allocation of health care services and supplies according to specified guidelines in order to determine whether and to what extent a service or supply will be provided or otherwise reimbursed. Such system may include one or more of the following: pre-admission certification, the application of practice guidelines, continued stay review, discharge planning, pre-authorization of specified procedures and retrospective review.
WORKERS' COMPENSATION (WC)

Liability insurance requiring certain employers to pay benefits and furnish medical care to employees injured and to pay benefits to dependents of employees killed in the course of and because of their employment.

WC MANUAL RATES
Premium rates charged to employers by insurers to provide workers' compensation coverage.
WORKERS' COMPENSATION MANAGED CARE ORGANIZATION (WCMCO)
Any entity that manages the utilization of care and costs associated with claims covered by workers' compensation insurance, which must be approved by DOBI in accordance with N.J.A.C. 11.6-1 et seq.
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