N.J. Admin. Code § 11:24-3.7 - Complaint and appeal system

(a) Every HMO shall establish and maintain a system to provide for the presentation and resolution of complaints brought by members or by providers acting on behalf of a member and with the member's consent, regarding any aspect of the HMO's health care services, including, but not limited to, complaints regarding quality of care, choice and accessibility of providers, network adequacy and adverse benefit determinations. All such general complaint systems must, at a minimum, incorporate to the satisfaction of the Commissioner, the following components:

1. Written notification to all members and providers of the telephone numbers and business addresses of the HMO employees responsible for complaint resolution;

2. A system to record and document the status of all complaints, which shall be maintained for at least three years;

3. Availability of an HMO member services representative to assist members, as requested, with complaint procedures;

4. Establishment of a specified response time for complaints, not to exceed 30 days from receipt thereof by the HMO or, if applicable, the time frames specified in N.J.A.C. 11:24-8;

5. A process describing how complaints are processed and resolved;

6. Procedures for follow-up action including the methods to inform the complainant of resolution;

7. Procedures for notifying the continuous quality improvement program of all valid complaints related to quality of care; and

8. A mechanism for notifying members and providers in writing that they may contact the Department, in the case of Medicaid enrollees, the Division of Medical Assistance and Health Care Services within the Department of Human Services, or, in the case of Medicare beneficiaries, the Health Care Financing Administration within the United States Department of Health and Human Services, if dissatisfied with the resolution reached through the HMO's internal complaint system.

(b) Every HMO shall provide for the presentation to the HMO and resolution by the HMO of complaints brought by providers in accordance with N.J.A.C. 11:24-3.7(a)2, 7.1(a)9 and 7.1(f).

(c) In addition to the process delineated in (a) above, every HMO shall establish and maintain a system for the presentation and resolution of appeals brought by members or by providers acting on behalf of a member and with the member's consent, with respect to adverse benefit determinations, except where the adverse benefit determination was based on a determination of group or member ineligibility, including rescission, or the application of a contract exclusion or limitation not related to medical necessity, which system shall comply with all of the provisions of N.J.A.C. 11:24-8.4 through 8.7.

(d) A description of the systems for filing complaints and for appealing adverse benefit determinations shall be included in the evidence of coverage and member handbook issued to members.

(e) No member or provider who exercises the right to file a complaint and/or appeal under this section shall be subject to disenrollment or otherwise penalized solely due to such complaint and/or appeal.

Notes

N.J. Admin. Code § 11:24-3.7

Recodified from N.J.A.C. 8:38-3.6 and amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
Rewrote (a)8. Former N.J.A.C. 8:38-3.7, Submission of documents and data, recodified to N.J.A.C. 8:38-3.8.
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
In the introductory paragraph of (a), deleted "and" preceding "network" and inserted "and adverse benefit determinations"; in (a)4, inserted "or, if applicable, the time frames specified in N.J.A.C. 11:24-8"; rewrote (c); and in (d), substituted "adverse benefit" for "utilization management".