N.J. Admin. Code § 11:24A-3.5

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24A-3.5 - Internal adverse benefit determinations appeals process

(a) A carrier shall establish an appeal process whereby a covered person or a provider acting on behalf of the covered person, with the covered person's consent, may appeal an adverse benefit determination, except where the adverse benefit determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to medical necessity, within 180 days of receipt of the adverse benefit determination.

(b) Carriers shall detail the appeal process in a writing provided to covered persons at the time of coverage (and periodically as changes occur), upon the occurrence of an adverse benefit determination, and upon the conclusion of each stage of the appeal process.

(c) Carriers shall provide a written description of the appeal process and the carrier's adverse benefit determination to providers upon the conclusion of each stage of the appeal process, when the provider is making the appeal on behalf of a covered person with the covered person's consent.

(d) The carrier shall not establish nor maintain any policies or procedures that prohibit or discourage a covered person from discussing or exercising the right to an appeal, including the right to designate a provider to act on behalf of the covered person in the appeal process.

(e) For covered persons in group health benefits plans, carriers shall establish an internal appeal process in two stages, with the stage 1 appeal being an informal process, and stage 2 being a formal process. For covered persons in individual health benefits plans, the internal appeal process shall consist of a stage 1 informal process.

(f) A carrier must provide the covered person and/or the provider acting on behalf of the covered person, free of charge, with any new or additional evidence or rationale, which will be relied upon, considered or utilized, or generated by the carrier (or at the direction of the carrier) in connection with the pre-service or post-service claim. Such evidence or rationale must be provided as soon as possible and sufficiently in advance of the date on which the final internal adverse benefit determination is required to be provided in order to give the covered person or provider a reasonable opportunity to respond prior to that date.

(g) An appeal concerning an urgent care claim may be submitted orally or in writing.

(h) The initial adverse benefit determination, as well as an adverse benefit determination following a stage 1 or stage 2 appeal, shall be culturally and linguistically appropriate pursuant to 45 CFR 147.136(e) and shall include:

1. Information sufficient to identify the claim involved, including date of service, health care provider, claim amount (if applicable) and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and treatment code and its corresponding meaning. Any such request for such diagnosis and treatment information following an initial adverse benefit determination shall be responded to as soon as practicable, and the request itself shall not be considered a request for a stage 1, stage 2 or stage 3 appeal;

2. The reason(s) for the adverse benefit determination, including denial code and corresponding meaning, as well as a description of the standard used by the carrier in the denial; and

3. Information regarding the availability and contact information for the consumer assistance program at the Department of Banking and Insurance, which assists covered persons with claims, internal appeals and external appeals, which shall include the address and telephone number at 11:24A-3.6(b).

(i) A carrier shall provide continued coverage of an ongoing course of treatment pending the outcome of a stage 1 internal appeal, a stage 2 internal appeal and an external appeal.

(j) Carriers shall provide in stage 1 for a covered person (or his or her designated provider if the covered person has consented to having a provider act in his or her behalf) to have an opportunity to speak, regarding an adverse benefit determination, with the carrier's medical director, or the medical director's designee who rendered the adverse benefit determination.

1. Stage 1 appeals shall be concluded as soon as possible in accordance with the medical exigencies of the case, but in no event shall exceed:

i. Seventy-two hours in the case of an appeal from an adverse benefit determination regarding urgent or emergency care, an admission, availability of care, continued stay and health care services for which the claimant received emergency services but has not been discharged from a facility; and

ii. Ten calendar days in the case of all other appeals.

2. At the conclusion of stage 1, the carrier shall include a written explanation of the covered person's right to file a stage 2 appeal for persons covered by a group health benefits plan, or to file an appeal with the Independent Health Care Appeals Program for persons covered by an individual health benefits plan, including the applicable time limits for filing the appeal, and to whom the stage 2 appeal should be addressed for persons covered by group health benefits plans or the form required to initiate an appeal with the Independent Health Care Appeals Program for persons covered by an individual health benefits plan.

(k) Carriers shall provide in stage 2 appeals for a covered person (or the covered person's designated provider, if the covered person has consented to have a provider act in his or her behalf) to pursue his or her appeal before a panel of physicians and/or other providers selected by the carrier who have not been involved in the adverse benefit determination at issue.

1. The panel shall have access to consultant providers who are trained or who practice in the same specialty as would typically manage the case at issue, or such other licensed provider as may be mutually agreed upon by the parties. The consulting provider(s) shall not have been involved in the adverse benefit determination at issue.

2. The carrier shall send to the covered person (or designated provider if the covered person has consented to having a provider act in his or her behalf) an acknowledgment of the filing of a stage 2 appeal in writing within no more than 10 business days of receipt by the carrier of the appeal.

3. The carrier shall conclude the stage 2 appeal as soon as possible after receipt of the appeal by the carrier in accordance with the medical exigencies of the case, but in no event shall the time to conclude the stage 2 appeal exceed 72 hours in the case of appeals of determinations regarding urgent or emergent care, an admission, availability of care, continued stay and health care services for which the claimant received emergency services but has not been discharged from a facility, and which in no event shall exceed 20 business days in the case of all other appeals.

4. In the event the stage 2 appeal results in a denial, the carrier shall provide the covered person and/or provider, as appropriate, with written notification of the denial and the reasons therefor together with a written notification of his or her right to proceed to an appeal through the Independent Health Care Appeals Program, including:

i. Specific instructions as to how the covered person and/or provider, as appropriate, may pursue such an appeal; and

ii. The form(s) required to initiate such an appeal.

(l) A covered person and/or provider shall be relieved of his or her obligation to complete the carrier's internal review process and may, at his or her option, proceed directly to the external appeals process set forth at 11:24A-3.6 if:

1. The carrier fails to comply with any of the deadlines for completion of the internal adverse benefit determination appeals set forth in this section unless the carrier's violation does not cause, and is not likely to cause, prejudice or harm to the covered person and/or provider, so long as the carrier demonstrates that the violation was for good cause or due to matters beyond the control of the carrier and that the violation occurred in the context of an ongoing, good faith exchange of information between the carrier and the covered person and/or provider, and is not reflective of a pattern or practice of non-compliance by the carrier.

i. The covered person and/or provider may request a written explanation of the violation from the carrier, and the carrier shall provide such explanation of the violation within 10 days, including a specific description of its bases, if any, for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted.

ii. If an external reviewer or a court rejects the covered person's and/or provider's request for immediate review on the basis that the carrier met the standards for the exception set forth in this paragraph, the covered person and/or provider has the right to resubmit and pursue the internal appeal of the claim. In such a case, within a reasonable time after the external reviewer or court rejects the claim for immediate review, not to exceed 10 days, the carrier shall provide the covered person and/or provider with notice of the opportunity to resubmit and pursue the internal appeal. The time period for refiling the claim shall begin to run upon the covered person's and/or provider's receipt of such notice;

2. The carrier for any reason expressly waives its rights to an internal review of any appeal; or

3. The covered person and/or provider has applied for expedited external review at the same time as applying for an expedited internal appeal.

N.J. Admin. Code § 11:24A-3.5

Amended by R.2012 d.035, effective Februay 6, 2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Section was "Internal utilization management appeals process". Rewrote (a), (b), (c) and (e); added new (f) through (i); recodified former (f) and (g) as (j) and (k); rewrote (j) and (k); and added ( l).