The cost of reviews is fixed through the procurement process. Carriers bear the costs of both the preliminary and full review, and once a preliminary or full review is initiated, the carrier is responsible for the associated costs of that portion of the review, even if the carrier elects to reverse its own decision prior to the IURO rendering a decision on the matter, or the individual, or health care provider, as appropriate, elects to withdraw the appeal.

A $25.00 filing fee may be billed to the applicant. Instructions on how to remit payment will be included with the invoice/bill for the filing fee when applicable.

Appeals under the IHCAP are not eligible for review if:

Upon receipt of the appeal, the IURO will conduct a preliminary review, and accept the appeal for processing if the IURO determines the following:

For Standard External Appeal Requests:

The IURO will complete the preliminary review and notify the covered individual, representative and/or health care provider as appropriate, in writing of whether the appeal has been accepted for processing within five (5) business days of receipt of the request.

The IURO will also notify the covered individual, representative and/or health care provider of his or her right to submit in writing, within five (5) business days of the receipt of acceptance of the appeal, any additional information to be considered in the IURO's review. Any additional information that is submitted will be shared with the covered person’s Health Carrier.

For Expedited External Appeal Requests:

Upon receipt of a completed expedited appeal request, the IURO will complete the preliminary review and notify covered individual, representative and/or health care provider, as appropriate, in writing as soon as possible of whether the appeal has been accepted for expedited processing.

The IURO will also notify the covered individual, representative and/or health care provider of his or her right to submit in writing, by a specified time and date any additional information to be considered in the IURO's review. Any additional information that is submitted will be shared with the covered person’s Health Carrier.

If an appeal is eligible for external review, the IURO will conduct a "full review" to determine whether an individual has been inappropriately denied medically necessary covered services by the carrier.

When performing the full review, the IURO relies on all information submitted by the parties to the matter that is deemed appropriate by the IURO, including:

The Decision:

The IUROs use impartial consultant medical professionals to review cases.  All decisions are approved by the IURO's medical director.

The IURO may uphold, reverse or modify the utilization management decision of the carrier. A modification means that the IURO upholds a portion of the carrier's utilization management decision and reverses a portion of it.

The IURO cannot recommend that services other than those at issue in the appeal be provided.

The written decision of the IURO, and the reasons for the decision, is sent to the covered individual, representative and/or health care provider, as appropriate, as well as to the carrier, and to the Department. The IURO's decision is binding on the covered individual and carrier, except to the extent that other remedies are available to either party under State or Federal law.

How long will it take for my External Appeal to be Decided?

The IURO will make a decision as soon as possible and this will not be more than 45 calendar days from when your request for an appeal was submitted.

What if I can’t wait that long?

You or your representative could request an expedited appeal.  Expedited reviews are decided by the IURO within 48 hours from when the appeal request was submitted.

What qualifies as an Expedited External Appeal?

Expedited appeals are for urgent or emergent cases.  An appeal can be expedited if:

• it involves a request for an admission to a health care facility;
• it involves a request for a continued stay after admission and you have not been discharged from the facility; or
• it involves a medical condition for which the standard review time frame would seriously jeopardize your life or health or jeopardize your ability to regain maximum function.

In order to qualify for an expedited review, you cannot have received all of the services being appealed.

How do I appeal?

You can file an external appeal electronically at https://njihcap.maximus.com

Persons who are unable to submit a request for an external appeal electronically can download the appeal form from the Maximus website above. Persons may also contact Maximus and ask that an appeal from be sent to them by regular mail and/or by fax.

What should I include with my appeal application?

The following documentation should be submitted with your appeal application:

• A copy of the Stage 1 and/or Stage 2 written decision(s) from the carrier. (If you are covered by an individual health benefits plan or a Medicaid HMO, you will only have one written decision [Stage 1] from the carrier.)
• A copy of the summary of coverage from your member handbook, certificate of coverage or other evidence of coverage issued by your carrier.
• If a health care provider filing on behalf of a member, a copy of the member's consent to have an appeal of the adverse utilization management decision made on his or her behalf. Whenever possible, please use Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims.
• A copy of all medical records and correspondence to be reviewed by the Independent Health Care Appeals Program.

You can also submit any other information you feel would be helpful for the IURO to have when it reviews your appeal.  Please note that any information that is submitted for the appeal will be shared with the covered person’s Health Carrier.

How do I submit my appeal?

You can complete your application and submit all required documents online at https://njihcap.maximus.com

If unable to apply electronically, the completed appeal form can be returned to Maximus by fax or mail as set forth below.

Questions about the application process can be directed to Maximus Federal by calling 888-866-6205 or e-mailing Stateappealseast@maximus.com.

The information related to, and the outcome of, any specific case is confidential, and is not subject to release by the IURO or the Department. However, the Department does produce a semi-annual report regarding the activities of the IHCAP for a six-month period, typically ending in February and August.

The Independent Health Care Appeals Reports, generated for the Legislature and Governor, are posted as they become available for release. The information contained in the semi-annual reports never identifies any individual or any details about any specific case. The information is presented in the aggregate, and provides information about the number of appeals processed, and the number of appeals upheld and reversed.