N.J. Admin. Code § 11:24-8.7

Current through Register Vol. 56, No. 17, September 3, 2024

Section 11:24-8.7 - External appeals process

(a) Any HMO member, and any provider acting on behalf of a member, with the member's consent, may appeal a final internal adverse benefit determination, except where the adverse benefit determination was based on a determination of group or member ineligibility, including rescission, or the application of a contract exclusion or limitation not relating to medical necessity, to an independent utilization review organization (IURO) in accordance with the procedures set forth below.

(b) A member and/or provider shall have a minimum of a four-month period from receipt of the 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 member in accordance with 11:24-8.6(e), and shall include both the fee specified in (c) below and a general release executed by the member 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 appeal shall be as follows:

1. Members or health care providers acting on a member's behalf shall pay a $ 25.00 filing fee, payable by check or money order to the "New Jersey Department of Banking and Insurance." The filing fee shall be refunded to the member or health care provider if the final internal adverse benefit determination is reversed by the IURO;

2. Upon a determination of financial hardship, the fee shall be waived. Financial hardship may be demonstrated by the member through evidence that one or more members of the household is receiving assistance or benefits under the Pharmaceutical Assistance to the Aged and Disabled, Medicaid, NJ FamilyCare, General Assistance, SSI or New Jersey Unemployment Assistance; and

3. Annual filing fees for any one member shall not exceed $ 75.00.

(d) Upon receipt of the appeal, together with the executed release, the Department shall immediately assign the appeal to an IURO in accordance with 11:24-8.8, for review.

(e) Upon receipt of the request for appeal from the Department, the IURO will conduct a preliminary review of the appeal and accept it for processing if it determines that:

1. The individual was or is a member of the HMO;

2. The service which is the subject of the complaint or appeal reasonably appears to be a covered service under the benefits provided by contract to the member;

3. Except as set forth at 11:24-8.6(f), the member has fully complied with the internal appeal process available pursuant to 11:24-8.5 and, if applicable, 8.6; and

4. The member has provided all information required by the IURO and the Department to make the preliminary determination, including the appeal form and a copy of any information provided by the HMO regarding its decision to deny, reduce or terminate the covered service, and a fully executed release to obtain any necessary medical records from the HMO and any other relevant health care provider.

(f) Upon completion of the preliminary review, the IURO shall immediately notify the member and/or provider in writing as to whether the appeal has been accepted for processing and if not so accepted, the reasons therefor. The IURO shall additionally notify the member and/or provider of his or her right to submit in writing, within five business days of the member's or provider's 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 HMO with any such additional information within one business day of receipt of the information.

(g) Upon acceptance of the appeal for processing, the IURO shall conduct a full review to determine whether, as a result of the HMO's final internal adverse benefit determination, the member was deprived of coverage of medically necessary covered services. In reaching this determination the IURO shall take into consideration all pertinent medical records, consulting physician reports and other documents submitted by the parties, any applicable, generally accepted practice guidelines developed by the Federal government, national or professional medical societies, boards and associations, and any applicable clinical protocols and/or practice guidelines developed by the HMO pursuant to 11:24-8.1(b).

(h) The IURO shall refer all appeals for full review, as referenced in (g) above, to an expert physician in the same specialty or area of practice who would generally manage the type of treatment that is the subject of the appeal. All final decisions of the IURO shall be approved by the medical director of the IURO, who shall be a physician licensed to practice in New Jersey.

(i) The IURO shall complete its review and issue its decision as soon as possible in accordance with the medical exigencies of the case which, except as provided for in this subsection, in no event shall exceed 45 days from receipt of the request for IURO review.

1. Notwithstanding (i) 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) If the IURO determines that the member was deprived of coverage of medically necessary covered services, the IURO shall advise the member and/or provider who filed the appeal, the HMO and the Department, as to the appropriate covered health care services the member should receive.

(k) The IURO's determination shall be binding on the HMO and the member, except to the extent that other remedies are available to either party under State or Federal law. The HMO shall provide benefits (including authorization of a service or supply and payment on the claim) pursuant to the IURO's determination and comply with the IURO's determination without delay, but no later than 10 business days from receipt of the IURO's determination, regardless of whether the HMO intends to seek judicial review of the external review decision, unless there is a judicial decision stating otherwise.

1. The HMO shall provide benefits to comply with the IURO's decision sooner if the medical exigencies of the case warrant a more rapid response.

(l) Nothing in this section shall limit the authority of the Division of Medical Assistance and Health Services (DMAHS) or the Department of Human Services (DHS) to adopt in any contract to provide HMO services to Medicaid recipients, its own process for appeals of utilization management determinations. At the request of the Commissioner of Human Services, the Commissioner shall adopt, in accordance with 52:14B-1 et seq. and N.J.A.C. 1:30, any such appeals process proposed by DMAHS or DHS as the exclusive appeals process for all Medicaid HMO members, if he or she find that it meets or exceeds the standards set forth in this chapter.

N.J. Admin. Code § 11:24-8.7

Amended by 50 N.J.R. 564(a), effective 1/16/2018