N.J. Admin. Code § 11:24A-3.6

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

Section 11:24A-3.6 - Independent health care appeals process

(a) Any covered person, and any provider acting on behalf of a covered person with the covered person's consent, may appeal a final internal adverse benefit determination, except where the final internal adverse benefit determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to medical necessity, through the Independent Health Care Appeals Program to an independent IURO.

(b) To initiate an appeal through the Independent Health Care Appeals Program, a covered person or provider acting on behalf of a covered person with the covered person's consent shall have a minimum four-month period from the date of receipt of the carrier's final internal adverse benefit determination to file a written request with the Department for an IURO appeal. The request shall be filed on the forms automatically provided to the covered person in accordance with 11:24A-3.5(k)4, and shall include both the fee specified in (c) below and a general release executed by the covered person for all medical records pertinent to the appeal. The request shall be mailed to the following address:

Department of Banking and Insurance

Consumer Protection Services

Office of Managed Care

PO Box 329

Trenton, New Jersey 08625-0329

(888) 393-1062

(c) The fee for filing an IURO appeal shall be as follows:

1. Covered persons or health care providers acting on a covered person's behalf shall pay a $ 25.00 filing fee, payable by check or money order to the "New Jersey Department of Banking and Insurance." The filing fee shall be refunded to the covered person or health care provider if the final internal adverse benefit determination is reversed by the IURO;

2. Upon a determination of financial hardship, the fee shall be waived. Financial hardship may be demonstrated by the covered person through evidence that one or more members of the household is receiving assistance or benefits under the Pharmaceutical Assistance to the Aged and Disabled, Medicaid, NJ FamilyCare, General Assistance, SSI or New Jersey Unemployment Assistance; and

3. Annual filing fees for any one covered person shall not exceed $ 75.00.

(d) Upon receipt of the request for appeal from the Department, the IURO shall conduct a preliminary review of the appeal and accept it for processing if it determines that:

1. The individual was or is a covered person of the carrier specified;

2. The service that is the subject of the appeal reasonably appears to be a service covered under the terms of the contract or policy for which some level of benefit is payable; and

3. The covered person or provider acting on behalf of a covered person with the covered person's consent has provided all information required by the IURO and the Department to make a preliminary determination, including the appeal form and a copy of any information provided by the carrier regarding its final adverse benefit determination, and a fully-executed release to obtain any necessary medical records from the carrier and any relevant provider.

(e) Upon completion of the preliminary review, the IURO immediately shall notify the covered person and/or provider in writing as to whether the appeal has been accepted for processing, and if not, the reasons therefor. The IURO shall additionally notify the covered person and/or provider of his or her right to submit in writing, within five business days of receipt of the notice of acceptance of his or her appeal, any additional information to be considered in the IURO's review. The IURO shall provide the carrier with any such additional information within one business day of receipt of the information.

(f) Upon acceptance of the appeal for processing, the IURO shall conduct a full review to determine whether, as a result of the carrier's final internal adverse benefit determination, the carrier inappropriately denied services, or the payment of benefits therefor, for the provision of medically necessary treatment or supplies that were/are covered under the contract or policy, taking into consideration the following:

1. All pertinent medical records, consulting physician reports and other documents submitted by the parties;

2. Applicable generally accepted practice guidelines developed by the Federal government, national or professional medical societies, boards and associations; and

3. Applicable clinical protocols and/or practice guidelines developed or used by the carrier, if any.

(g) The IURO shall refer all cases for full review, as referenced in (f) above, to an expert physician in the same specialty or area of practice that generally would manage the type of treatment that is the subject of the appeal, but shall not render a final recommendation except with the approval of the IURO's medical director, who shall be a physician licensed to practice in New Jersey.

(h) The IURO shall complete its review and issue its decision in writing as soon as possible consistent with the medical exigencies of the case, but in no instance later than 45 days following the date of receipt of the request for IURO review.

(i) Notwithstanding (h) above, if the appeal involves care for an urgent or emergency case, an admission, availability of care, continued stay, health care services for which the claimant received emergency services but has not been discharged from a facility or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the IURO shall complete its review within no more than 48 hours following its receipt of the appeal. If the IURO's determination of the appeal provided within no more than 48 hours was not in writing, the IURO shall provide written confirmation of its determination within 48 hours of providing the verbal determination.

(j) The IURO shall set forth in its written decision whether the IURO has determined that the covered person was deprived of coverage of medically necessary services and, if so, shall specify the appropriate covered services the covered person should receive.

1. The IURO shall submit its decision to the covered person and his or her provider (if the provider assisted in filing the appeal with the covered person's consent), the carrier and the Department.

2. The IURO's determination shall be binding on the carrier and the covered person, except to the extent that other remedies are available to either party under State or Federal law. The carrier shall provide benefits (including payment on the claim) pursuant to the IURO's determination without delay, regardless of whether the carrier intends to seek judicial review of the external review decision, unless there is a judicial decision stating otherwise.

N.J. Admin. Code § 11:24A-3.6

Amended by R.2005 d.418, effective 11/21/2005.
See: 37 N.J.R. 2174(a), 37 N.J.R. 4536(a).
In (i) and throughout (k), substituted "decision" for "recommendation"; in the introductory paragraph of (k), added ", if so,".
Amended by R.2011 d.097, effective 4/4/2011.
See: 42 N.J.R. 2920(a), 43 N.J.R. 880(a).
In the introductory paragraph of (b), deleted ", as set forth in Exhibit 1 of the chapter Appendix, incorporated herein by reference" following "with the Department", and inserted the last two sentences.
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Rewrote the section.