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-3.6 - Independent health care appeals process
Current through Register Vol. 56, No. 6, March 18, 2024
(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:
(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:
(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:
(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.