Individuals covered under a health benefits plan that uses one or more utilization management (UM) features, has the right to appeal a UM determination that results in a denial, termination or limitation of covered services. Or the covered person may give consent to a health care provider to pursue the UM appeal on the covered person's behalf. A UM determination is a decision made by the carrier about the medical necessity or appropriateness of a particular health care service covered under the terms of the health benefits plan. A UM determination may be made before or after a health care service is rendered, depending upon the terms of the policy.

A carrier that makes UM determinations must have a two-stage internal appeal mechanism. The carrier must provide covered individuals with a written explanation of how to access the internal appeal mechanism. This explanation may be in the member handbook or a certificate of coverage, or it may be in a separate document. In addition, the carrier must provide information to the covered individual, or the health care provider, when appropriate, about how to appeal unfavorable UM determination each time the carrier makes such an unfavorable UM determination.

The second stage of appeal must be initiated within 180 days following receipt of an unfavorable stage one decision. The second stage of appeal is more formal, and usually takes longer. A decision should be rendered for this stage of appeal within 20 business days from the date of receipt of the stage two appeal request.The appeal will be reviewed by a panel of physicians and/or other health care professionals who have not been involved with the case earlier, but who are knowledgeable about the particular condition and services at issue. The panel, convened by the carrier, shall have access to health care professionals who are part of the carrier's network, or outside consultants in an appropriate specialty, or both. Some carriers offer the covered individual, or health care provider an opportunity to speak with the panel.

If the carrier's UM determination after the stage two appeal does not change, the carrier must give the covered individual (or health care provider, as appropriate) information about how to pursue the appeal externally, and supply the appropriate form to file with the Independent Health Care Appeals Program (IHCAP).

If an insurance company does not comply with the time frames for completion of a Stage 1 or Stage 2 appeal, the covered person and/or the provider generally has the right to proceed directly to an external appeal.  In addition, a covered person or provider can bypass the internal appeal and proceed directly to an external appeal if the insurance company waives its right to an internal review or if the covered person or provider has simultaneously applied for an expedited internal review and an expedited external review.

A request for an external appeal must typically be filed within four months of receipt of the decision on the internal appeal. Persons covered by Medicaid have 60 days from receipt of the decision on the internal appeal to request an external appeal.  The covered person or provider should electronically file the request for external appeal by providing the information requested at:

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

The covered person or provider should include with the request for an IURO appeal:

• All information submitted to the Insurance company
• Any additional information the covered person or provider wants considered by the IURO
• The insurance company’s initial UM denial
• The insurance company’s decision(s) on the internal appeal(s).

The IURO will refer the case to a physician in the appropriate specialty and complete its review as soon as possible in accordance with the medical exigencies of the case, which will not exceed 45 days.  Review time is limited to 48 hours in appeals involving urgent or emergency care, an admission, availability of care, continued stay, situations in which the covered person received emergency services but has not been discharged, and cases where the standard 45 day review time would jeopardize the life or health of the covered person or jeopardize the covered person’s ability to regain maximum function.

The decision of the IURO is binding on the carrier and the covered person, except if other remedies are available under state or federal law.  There is a $25 processing fee for applications accepted for review by the IURO.  The fee is waived for persons who demonstrate financial  hardship and for persons who are successful in their appeal.  If the IURO’s decision is adverse to the covered person, the IURO will bill the $25 processing fee to the covered person or provider.  The IURO’s decision and the records provided to it are confidential.  The Department issues semi-annual reports on the IURO program which can be found at www.state.nj.us/dobi/division_insurance/managedcare/ihcapreports.htm.