If the panel determines that the proposed medical treatment is appropriate, the panel upholds the plan. However, if the panel determines that the consumer is being denied medically appropriate care, the panel decides in favor of the consumer. Once the panel has made its determination, the plan has 10 days to either accept or reject the recommendation. The last column shows the plan's decision to accept or reject the panel's recommendation, or whether the plan is still within the 10 day timeframe to make its final decision. A recent report prepared for the Kaiser Family Foundation on external review programs established by a state or federal agency, shows that New Jersey is one of 18 states to establish a process for an independent review of health plan decisions that deny coverage for enrollee health services.
New Jersey is one of the states featured in the report.
However, New Jersey is one of only two states in which external review decisions are not binding. The report found that, as in New Jersey, the number of cases brought to external review is quite low in all state programs. As expected, the Medicare external appeal process, by far, has the largest caseload. This can largely be attributed to Medicare's requirement for health plans to automatically send all denials upheld by the health plan's internal review process for external review. The experience in New Jersey is also consistent with the finding that independent panels uphold the health plans decision about as frequently as it overturns them.