Steps to take if you have been denied covered medical benefits or want to file a complaint.

To Appeal a Health Plan Decision

Your plan is required to have an appeal process that gives you an opportunity to resolve disagreements about denial of a covered benefit:

Preliminary Stage
Review the services covered by your plan and the explanation of the appeal process in the plan's member handbook. You or your doctor, acting with your consent, have the right to file an appeal.

Stage 1
Inform the plan, either verbally or in writing, of your dissatisfaction with the plan's decision to deny or limit services you believe are covered.

Stage 2
If you are dissatisfied with the results of the initial communications with the plan, you can request, either verbally or in writing, that the plan have your appeal reviewed by a panel of doctors and other health care professionals not involved in your case.

Stage 3
If you are dissatisfied with the plan's decision on your appeal, you can file an appeal with the Department of Health and Senior Services within 60 days of receiving the plan's Stage 2 decision. Your case will be reviewed by independent experts under contract to the State through the Independent Health Care Appeals Program (IHCAP).

For appeals involving urgent circumstances, the plan is required to respond within 72 hours in Stages 1 and 2.

To File a Health Plan Complaint

In addition to the appeal process for denial of a covered benefit, you also have the right to complain to the health plan about any aspect of its operations. Your plan 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 a plan's business and marketing practices. The plan is required to respond to your complaint within 30 days. The plan's member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the resolution reached through the plan's complaint process, contact the appropriate State agency:

For complaints about quality of care, choice of providers or access to network providers:

NJ Dept. of Health and Senior Services
Office of Managed Care
PO Box 360
Trenton, NJ 08625-0360
(888) 393-1062

For complaints about business practices such as claims payment, member enrollment or termination of coverage:

NJ Dept. of Banking and Insurance
Division of Enforcement and Consumer Protection
PO Box 329
Trenton, NJ 08625-0329
(800) 446-7467

Note: The process for appealing a decision or filing a complaint is different if you belong to a "self-insured" plan. Check with your employer or health plan and refer to Contacting Your Health Plan.