There were individual cases involving denials of equipment, skilled nursing care, speech or physical therapy, mental health care, home health, and the use of an out of network provider. In more than half the cases, the appeal was filed after the service was provided. Of the 69 appeals completed during this time period, the independent panel supported the HMO's decision 40 times and recommended in favor of consumers 29 times. The appeal panel's recommendations in favor of consumers were accepted by the managed care plan 25 times and rejected in 4 cases. At this time, the Department has not identified a pattern of non- compliance with the findings and recommendations of the review panel.
New Jersey is one of only two states with a non-binding appeals process.
Only some five states had an external appeals system when New Jersey began its program in 1997. Since then, we have been active in assisting other states, as well as the federal government as they considered legislation to establish an appeals process. Consumer education By law, patients who are turned down for a medical procedure must be given an appeal form with instructions on how to appeal. Nevertheless, we take every opportunity to publicize this appeal right. We are currently working on a booklet about how to appeal a decision by managed care organizations and plan to distribute it to doctors' offices and other locations around the state.