N.J. Admin. Code § 11:24-8.6

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

Section 11:24-8.6 - Formal internal utilization management appeal process (Stage 2)

(a) Each HMO shall establish and maintain a formal internal appeal process (stage 2 appeal) whereby any member covered by a group health benefits plan or any provider acting on behalf of a member covered by a group health benefits plan with the member's consent, who is dissatisfied with the results of the stage 1 appeal, shall have the opportunity to pursue his or her appeal before a panel of physicians and/or other health care professionals selected by the HMO who have not been involved in the adverse benefit determination at issue.

(b) The formal internal utilization management appeal panel shall have access to consultant practitioners who are trained or who practice in the same specialty as would typically manage the case at issue, or such other licensed provider as may be mutually agreed upon by the parties. In no event, however, shall the consulting practitioner or professional have been involved in the adverse benefit determination at issue.

(c) All such stage 2 appeals shall be acknowledged by the HMO, in writing, to the member or provider filing the appeal within 10 business days of receipt.

(d) All such stage 2 appeals shall be concluded as soon as possible after receipt by the HMO in accordance with the medical exigencies of the case, which in no event shall exceed 72 hours in the case of appeals from determinations regarding urgent or emergent care, an admission, availability of care, continued stay and health care services for which the claimant received emergency services but has not been discharged from a facility, and which in no event shall exceed 20 business days in the case of all other appeals.

(e) If the stage 2 appeal is denied, the HMO shall provide the member and/or provider with written notification of the denial and the reasons therefor together with a written notification of his or her right to proceed to an external (stage 3) appeal. This notification shall include specific instructions as to how the member and/or provider may arrange for an external appeal and shall also include any forms required to initiate such an appeal.

(f) A member and/or provider shall be relieved of his or her obligation to complete the HMO internal review process and may, at his or her option, proceed directly to the external appeals process set forth at 11:24-8.7 if:

1. The HMO fails to comply with any of the deadlines for completion of the internal adverse benefit determination appeals set forth in 11:24-8.5 or 8.6, unless the HMO's violation does not cause, and is not likely to cause, prejudice or harm to the member and/or provider, so long as the HMO demonstrates that the violation was for good cause or due to matters beyond the control of the HMO and that the violation occurred in the context of an ongoing, good faith exchange of information between the HMO and the member and/or provider, and is not reflective of a pattern or practice of non-compliance by the HMO.

i. The member and/or provider may request a written explanation of the violation from the HMO and the HMO shall provide such explanation of the violation within 10 days, including a specific description of its bases, if any, for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted.

ii. If an external reviewer or a court rejects the member's and/or provider's request for immediate review on the basis that the HMO met the standards for the exception set forth in this paragraph, the member and/or provider has the right to resubmit and pursue the internal appeal of the claim. In such a case, within a reasonable time after the external reviewer or court rejects the claim for immediate review, not to exceed 10 days, the HMO shall provide the member and/or provider with notice of the opportunity to resubmit and pursue the internal appeal. The time period for refiling the claim shall begin to run upon the member's and/or provider's receipt of such notice;

2. The HMO for any reason expressly waives its rights to an internal review of any appeal; or

3. The member and/or provider has applied for expedited external review at the same time as applying for an expedited internal appeal.

N.J. Admin. Code § 11:24-8.6

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
In (d), inserted "(including all situations in which the member is confined as an outpatient)" following "care".
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Rewrote (a), (b) and (d); deleted former (e); recodified former (f) as (e); added new (f); recodified former (g) as the introductory paragraph of (f)1 in part and as (f)2 in part; rewrote (f)1 and (f)2; and added (f)1i, (f)1ii and (f)3.