New Jersey Administrative Code › Title 17 - TREASURY - GENERAL › Chapter 9 - STATE HEALTH BENEFITS PROGRAM › Subchapter 1 - ADMINISTRATION › Section 17:9-1.3 - Appeals from Commission decisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any member of
				the SHBP who disagrees with the decision of the carrier and has exhausted all
				appeals within the plan, as well as any external review required by the PPACA,
				if applicable, may request that the matter be considered by the Commission.
				Requests for consideration must be directed to the Secretary of the Commission
				within one year of the plan's final adverse benefit determination, and must
				contain the reason for the disagreement and all available supporting
				documentation. Appeals shall be considered at the regular meetings of the
				Commission. It shall be the responsibility of the member to provide the
				Commission with any medical or other information that the Commission may
				require in order to make a decision.
(b) Any person who disagrees with a
				determination made by the Division regarding their enrollment or eligibility in
				the SHBP, may request that the matter be considered by the Commission.
(c) Notification of all Commission
				decisions will be made in writing to the member and the following statement
				shall be incorporated in every written notice setting forth the Commission's
				determination in a matter where such determination is contrary to the claim
				made by the claimant or his or her legal representative:
"If you disagree with the determination of the Commission in
				  this matter, you may appeal by sending a written statement to the Commission
				  within 45 days from the date of this letter informing the Commission of your
				  disagreement and all of the reasons therefor. If no such written statement is
				  received within the 45-day period, this determination shall be considered
				  final."
(d) If a member
				disagrees with the Commission's decision and submits the written statement set
				forth in (c) above within 45 calendar days, the Commission shall determine
				whether to grant an administrative hearing on the basis of whether the matter
				involves contested facts or is solely a question of law. The Commission will
				then notify the member of the disposition of the appeal.
1. If the appeal involves solely a question
				of law, the Commission shall likely deny an administrative hearing request. If
				the request for an administrative hearing is denied, the Commission shall issue
				detailed findings of fact and conclusions of law. These findings and
				conclusions shall become the Commission's final administrative determination
				that may then be appealed to the Superior Court, Appellate Division.
2. If the appeal involves disputed facts, the
				Commission shall approve an administrative hearing request and transmit the
				matter to the Office of Administrative Law. Upon completion of this hearing,
				the Administrative Law Judge will submit to the Commission an initial decision
				that the Commission may adopt, reject or modify. If the Commission rejects or
				modifies the initial decision, it shall issue detailed findings of fact and
				conclusions of law that will become the Commission's final administrative
				determination that may then be appealed to the Superior Court, Appellate
				Division.