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How to File a Utilization Management Appeal |
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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. |
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Stage 1 |
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For persons enrolled in group health plans, the first stage of appeal must be initiated within 180 days following the receipt of an unfavorable UM determination. Some carriers may specify a shorter timeframe for filing Stage 1 appeals when someone is covered under an individual policy or through Medicaid managed care plans. The first stage of appeal is informal, and generally fairly quick. Typically, a decision will be rendered within 10 calendar days from the receipt of the appeal.* If the covered individual or health care provider is not happy with the UM determination after the Stage 1 appeal, the covered individual or health care provider can take the appeal to the second stage. |
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Stage 2 |
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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 (MS Word) (or Medicaid version) to file with the Independent Health Care Appeals Program (IHCAP). |
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Stage 3 |
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Individuals, or health care providers acting with the individual's consent, who want to use the Independent Health Care Appeals Process (IHCAP), the third stage of appeal, must submit the appropriate form (MS Word) (or Medicaid version) to the Department within four months after receiving the carrier's written decision for the stage two appeal, along with the filing fee. The fee for filing with the Independent Health Care Appeal Program is $25, but the fee may be waived for individuals who can demonstrate eligibility for government assistance. The form and fee should be submitted to: |
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Please note that, on occasion, an individual may be permitted to by-pass a portion of the internal two-stage appeal process, and go directly to the external review. The request to by-pass the first and/or second stage of internal review must be based on the carrier's failure to meet the timeframes for the separate stages of appeal, the carrier's actual waiver of the requirement for the individual to pursue the first or second stage of appeal, or the covered individual and/or provider has applied for an expedited external review at the same time as applying for an expedited internal appeal. *For emergency and urgent care cases, an admission, availability of care, continued stay and health care services for which the claimant received emergency services but has not been discharged from the facility, the carrier must make its decision on the appeal consistent with the urgency of the case, and in no instance more than 72 hours from the time the appeal is received at stage one, and at stage two. The Department will make every effort to have a decision by an IURO made within 48 hours of receipt of an emergency or urgent care appeal request for external review. |
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Before You Mail Your Appeal to the Independent Health Care Appeals Program: | ||
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State of New Jersey New Jersey Department of Banking and Insurance |