N.J. Admin. Code § 11:24-8.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24-8.4 - Appeals of adverse benefit determinations

(a) All HMO members, and any provider acting on behalf of a member with the member's consent, may appeal any adverse benefit determination resulting in a denial, termination or other limitation of covered health care services in accordance with the provisions of 11:24-8.5 and 8.6 within 180 days of receipt of the adverse benefit determination. All members and providers shall be provided with a written explanation of the appeal process in the member handbook and upon the conclusion of each stage in the process as described in 11:24-8.5 through 8.7.

1. For HMO members covered by group health benefits plans, the appeal process shall consist of an informal internal review by the HMO (stage 1 appeal), a formal internal review by the HMO (stage 2 appeal), and a formal external review (stage 3 appeal) by an independent utilization review organization (IURO) through the Independent Health Care Appeals Program established pursuant to 26:2S-11, as further described at N.J.A.C. 11:24A-5.

2. For HMO members covered by individual health benefits plans, the appeal process shall consist of an informal internal review by the HMO (stage 1 appeal) and a formal external review (stage 3 appeal) by an independent utilization review organization (IURO) through the Independent Health Care Appeals Program established pursuant to N.J.S.A. 26:2S-11, as further described at N.J.A.C. 11:24-8.7.

(b) Nothing in the HMO's policies, procedures or provider agreement shall prohibit a member or provider (on behalf of a member) from discussing or exercising the right to an appeal available under 11:24-8.5 through 8.7.

(c) An HMO shall provide the member and/or the provider acting on behalf of the member, free of charge, with any new or additional evidence or rationale, which will be relied upon, considered or utilized, or generated by the HMO (or at the direction of the HMO) in connection with an adverse benefit determination on a pre-service or post-service claim. Such evidence or rationale must be provided as soon as possible and sufficiently in advance of the date on which the final internal adverse benefit determination is required to be provided in order to give the member or provider a reasonable opportunity to respond prior to that date.

(d) An appeal concerning an urgent care claim may be submitted orally or in writing.

(e) The initial adverse benefit determination, as well as an adverse benefit determination following a stage 1 or stage 2 appeal shall be culturally and linguistically appropriate pursuant to 45 CFR 147.136(e) and shall include:

1. Information sufficient to identify the claim involved, including date of service, health care provider, claim amount (if applicable) and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning. Any request for such diagnosis and treatment information following an initial adverse benefit determination shall be responded to soon as practicable, and the request itself shall not be considered a request for a stage 1, stage 2 or stage 3 appeal;

2. The reason(s) for the adverse benefit determination, including denial code and corresponding meaning, as well as a description of the standard used by the HMO in the denial; and

3. Information regarding the availability and contact information for the consumer assistance program at the Department of Banking and Insurance, which assists covered persons with claims, internal appeals and external appeals, which shall include the address and telephone number at 11:24-8.7 (b).

(f) An HMO shall provide continued coverage of an ongoing course of treatment pending the outcome of a stage 1 internal appeal, a stage 2 internal appeal and an external appeal.

N.J. Admin. Code § 11:24-8.4

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
In (a), added "through the Independent Health Care Appeals Program established pursuant to N.J.S.A. 26:2S-11, as further described at N.J.A.C. 8:38A-5" at the end.
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Section was "Appeals of utilization management determinations". Rewrote (a); and added (c) through (f).