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|2007 New Jersey HMO Performance Report|
|Appeals and Complaints|
To Appeal an HMO’s Decision
Your HMO is required to have an appeal process that gives you an opportunity to resolve disagreements about denial of covered benefits or services. Denials, limitations and terminations of covered services or benefits for such services that result from a decision by the HMO that the services are not medically necessary are adverse utilization management (UM) determinations.
Review the services covered by your HMO and the explanation of the appeal process in your evidence of coverage. You or your doctor, acting with your consent, have the right to file an appeal of an HMO’s UM determination.
For appeals involving urgent circumstances, the HMO is required to respond within 72 hours in Stages 1 and 2.
To File a Complaint against an HMO
In addition to the appeal process for adverse UM determinations, you also have the right to complain to the HMO about any aspect of its operations. The HMO 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 an HMO’s business and marketing practices. The HMO is required to respond to your complaint within 30 days. The HMO’s member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the outcome of the HMO’s complaint process, contact:
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State of New Jersey
New Jersey Department of Banking and Insurance