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 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS
Section 11:24A-4.12 - Internal utilization management appeal process

(a) A carrier shall establish an internal appeal mechanism whereby a covered person or a provider acting on behalf of a covered person, with the covered person's consent, may appeal any decision to deny, reduce or terminate services or the payment of benefits therefor covered under the contract or policy, in compliance with 11:24A-3.5.

(b) In addition to the requirements set forth in (a) above, a carrier shall provide a written explanation of the appeal process to all of its network providers, and to other providers upon request, as well as at the conclusion of each stage of the appeal process.

(c) In addition to (a) and (b) above the carrier shall not establish or maintain policies, procedures or set forth anything in provider agreements that prohibit or discourage a covered person or provider from discussing or exercising the right to an appeal available under this subchapter, or the right to an external appeal through the Independent Health Care Appeals Program at 11:24A-3.6.