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Appeals & Complaints

Know Your Rights: Appeals & Complaints.

You have the right to appeal a health plan decision
The state has a prescribed process which each plan is required to follow in order to resolve any disputes regarding denials. You must follow each stage of the process.

Preliminary Stage: Review the services covered by your plan and the explanation of the appeal process in the plan’s member handbook. You and your doctor, acting with your consent, have the right to file an appeal.

Stage 1: Inform the plan, either verbally or in writing, that you disagree with the plan’s decision to deny or limit services you believe are covered.

Stage 2: If you are dissatisfied with the results of the initial communication with your insurer, you can request, either verbally or in writing, that the plan have your appeal reviewed by a panel of doctors and other health care professionals.

Stage 3: If you are dissatisfied with the plan’s decision on your stage 2 appeal, you can file an appeal with the Department of Health and Senior Services within 60 days of receiving the plan’s Stage 2 decision. You will receive the form of instructions needed to file a STage 3 appeal from your health plan at the same time you receive the plan’s Stage 2 appeal decision.

Your case will be reviewed by independent experts under contract to the State through the Independent Health Care Appeals Program (IHCAP). Decisions made by the IHCAP are binding on the health plans.

For appeals involving urgent circumstances, the plan is required to respond within 72 hours in Stages 1 and 2.

The process for appealing a decision or filing a complaint is different if you belong to a “self-insured” plan or Medicare and Medicaid managed care plans. Check with your employer or health plan for more information.

Health Plan Complaints Not Related to Claims Denials

In addition to the appeal process for denial of a covered benefit, you also have the right to complain to the health plan about any aspect of its operations. Your plan is required to have a system to resolve complaints about such things as quality of medical care, choice of doctors, and other health care providers, and difficulties with processing claims or disputes about a plan’s business and marketing g practices. The plan is required to respond to your complaint within 30 days. The plan’s member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the outcome of the plan’s complaint process, contact:

NJ Department of Banking and Insurance, Division of Insurance, Consumer Protection Services
P.O. Box 329 | Trenton, NJ 08625-0329
(800) 446-7467