New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 3 - UTILIZATION MANAGEMENT › Section 11:24A-3.5 - Internal adverse benefit determinations appeals process

Current through Register Vol. 56, No. 14, July 15, 2024
(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).