To Appeal a Health Plan Decision

Your health plan is required to have an appeal process that provides you the opportunity to resolve disagreements about medical services. If you are dissatisfied with the result of the health plan's appeal process, you can have your case reviewed by an independent organization selected by the New Jersey Department of Health and Senior Services.

Here are steps to take if you believe you have been denied medical services covered by your health plan contract:

1. Review the medical services covered by your insurance contract and the explanation of the appeal process in the member handbook provided by the plan. Your health plan should inform you of your options at each stage of the process.

2. To begin the process of appeal, you should inform the health plan, either verbally or in writing, of your dissatisfaction with the health plan's decision to deny or limit services you believe are covered. You can communicate your appeal on your own or have a doctor do it for you with your permission. This is an opportunity for you or your doctor to discuss the issue with a physician from the health plan.

3. If you are not satisfied with the results of the initial communications with the health plan, you can request the health plan to have your appeal reviewed by a panel of doctors and other health care professionals not involved in your case. The panel members may either be part of the health plan's network or outside consultants in the relevant medical specialty. If the panel decides in favor of the health plan, you must receive written notification of the reasons why your appeal was denied. In addition, the health plan must give you instructions and forms so that you can take the process to the next stage and file your appeal with the Department of Health and Senior Services, if you choose.

4. You can file your appeal with the Department of Health and Senior Services within 60 days of receiving the health plan's denial. There is a fee of $25, which is reduced to $2 for those eligible for government assistance programs. An independent utilization review organization (IURO) will review your appeal. If the IURO determines you did not receive necessary medical services covered by the plan, it will recommend that the health plan provide the appropriate medical services. The health plan must then notify you or your doctor whether it accepts the IURO's recommendation. If it does not, it must explain the reasons for its rejection.

To File a Complaint

You also have the right to complain to the health plan about any aspect of its operations. New Jersey regulations require health plans to have a system to resolve complaints about such things as quality of medical care, choice of doctors and other health care providers, difficulties with health plan services, or disputes about plan business and marketing practices. The health plan is required to respond to your complaint within 30 days. The member handbook provided by the health plan contains a description of the complaint process and the tele- phone number and address of health plan staff responsible for resolving complaints.

If you are dissatisfied with the resolution reached through the health plan's complaint process, the State of New Jersey can assist you.

For complaints about quality of care, choice of providers or getting access to providers in a plan's network, contact:

Note: The process for appealing a health plan decision or filing a complaint is different if you are a member of a plan that is classified as "self-funded." Check with your employer or health plan to find out which process applies to you.

To learn more about the programs and services provided by the NJ Department of Health and Senior Services, visit our website: www.state.nj.us/health.