New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 74 - MANAGED HEALTH CARE SERVICES FOR MEDICAID/NJ FAMILYCARE BENEFICIARIES
Subchapter 11 - GRIEVANCE PROCEDURE
Section 10:74-11.2 - Medicaid/NJ FamilyCare fair hearing

(a) The contractor shall ensure that all Medicaid and NJ FamilyCare-Plan A and Plan D adult enrollees with incomes under 134 percent of the FPL, shall be informed, in a simple, brief statement, of their rights to a fair hearing in accordance with N.J.A.C. 10:49-10, and of the contractor's grievance review procedures. This may be accomplished by an annual mailing, as noted in 10:74-5.1(c)3, a member handbook or any other method that shall not diminish the enrollees' opportunity to be heard. Enrollees of all other NJ FamilyCare plans shall not have access to the fair hearing process described in N.J.A.C. 10:49-10. However, these beneficiaries shall be accorded all appeal rights consistent with the appropriate rules of the Department of Banking and Insurance. See N.J.A.C. 11:20-20 and 11:24-8.

(b) The contractor shall report all grievances to the Division with a brief statement of the problem and resulting outcome on a quarterly basis.

(c) The MCO shall provide written analysis, representation and expert witness services in fair hearings and in any subsequent hearings in any other court regarding any actions the MCO has taken regarding a beneficiary. In the case of a MCO's denial, modification, or deferral of a prior authorization request, the MCO shall present its position for the denial, modification, or deferral of procedures during fair hearing proceedings.