N.J. Admin. Code § 11:3-4.7B - Requirements for insurer internal appeals procedures
(a) The internal appeal procedure in an
insurer's Decision Point Review Plan (DPR Plan) shall meet the requirements in
this section.
(b) Insurers shall
only require a one-level appeal procedure for each appealed issue before making
a request for alternate dispute resolution in accordance with N.J.A.C. 11:3-5.
That is, each issue shall only be required to receive one internal appeal
review by the insurer prior to making a request for alternate dispute
resolution. An appeal of the denial of a medical procedure, treatment,
diagnostic test, other service, and/or durable medical equipment on the grounds
of medical necessity is a different issue than an appeal of what the insurer
should reimburse the provider for that same service.
(c) All appeals shall be initiated using the
forms established by the Department by Order in accordance with
N.J.A.C.
11:3-4.7(d) and posted on
the Department's website.
(d) The
appeal forms and any supporting documentation shall be submitted by the
provider to the address and/or fax number designated for appeals in the
insurer's DPR Plan. Pursuant to N.J.A.C. 11:1-47, insurers may permit
electronic filing of appeals by providing the process for electronic filing in
its DPR Plan.
(e) There shall be
two types of internal appeals:
1.
Pre-service: Appeals of decision point review and/or precertification denials
or modifications prior to the performance or issuance of the requested medical
procedure, treatment, diagnostic test, other service and/or durable medical
equipment (collectively known as "services"); and
2. Post-service: Appeals subsequent to the
performance or issuance of the services.
(f) A pre-service appeal shall be submitted
no later than 30 days after receipt of a written denial or modification of
requested services.
(g) A
post-service appeal shall be submitted at least 45 days prior to initiating
alternate dispute resolution pursuant to N.J.A.C. 11:3-5 or filing an action in
Superior Court.
(h) Decisions on
pre-service appeals shall be issued by the insurer to the provider who
submitted the appeal no later than 14 days after receipt of the pre-service
appeal form and any supporting documentation.
(i) Decisions on post-service appeals shall
be issued by the insurer to the provider who submitted the appeal no later than
30 days after receipt of the appeal form and any supporting
documention.
(j) Nothing in this
section shall be construed so as to require reimbursement of services that are
not medically necessary or to prevent the application of the penalty
co-payments in
N.J.A.C.
11:3-4.4(e), (f), and
(g).
Notes
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