New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS
Subchapter 3 - UTILIZATION MANAGEMENT
Section 11:24A-3.2 - Disclosure requirements

Universal Citation: NJ Admin Code 11:24A-3.2

Current through Register Vol. 56, No. 18, September 16, 2024

(a) In addition to the requirements of 11:24A-2.3, carriers shall include in the disclosure statements a covered person's right to appeal to the carrier an adverse benefit determination, except where the adverse benefit determination was based on eligibility, including rescission, or on the application of a contract exclusion or limitation not relating to medical necessity, setting forth:

1. A description of the internal appeal procedure, including the address and toll-free telephone number through which the covered person may contact the carrier;

2. The amount of time for a final decision on the appeal; and

3. The process for expediting appeals in urgent or emergency situations.

(b) The statement that a covered person has a right to appeal a carrier's final adverse benefit determination, except where the final adverse benefit determination was based on eligibility, including rescission, or on the application of a contract exclusion or limitation not relating to medical necessity, at the option of the covered person through the Independent Health Care Appeals Program, including:

1. The cost to the covered person of making such an appeal (that is, the cost of the application fee), and the right of the covered person to request a waiver from the Department for financial hardship;

2. A statement that the carrier shall bear the costs of the review by the Independent Health Care Appeals Program;

3. A statement that the covered person shall have a minimum four-month period to file the application for review of the carrier's final adverse benefit determination following the date the final internal adverse benefit determination was issued by the carrier; and

4. A statement that the decision of the Independent Health Care Appeals Program is binding upon the carrier.

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