Consumers
who receive health care services through either the Medicare
or Medicaid Fee-for-service or managed care plans have additional
avenues of appeal.
Filing
a Complaint
Filing
an Appeal
Helpful
Tips to Better Understanding Your Health Plan
Ask
the HCCAP staff
Commercial
Health Care Insurance
To File a Health Plan Complaint
In addition
to the appeal process for denial of a covered benefit, you also
have the right to complain to the health plan about any aspect
of its operations. Your plan is required to have a system to
resolve complaints about such things as quality of medical care,
choice of doctors and other health care providers, and difficulties
with processing claims or disputes about a plan’s business
and marketing practices. The plan is required to respond to your
complaint within 30 days. The plan’s member handbook contains
a description of the process and contact information for resolving
complaints. If you are dissatisfied with the outcome of the plan’s
complaint process, contact the appropriate State agency.
For complaints
about quality of care, choice of providers or access to network
providers contact:
NJ Department
of Health and Senior Services
Office of Managed Care
P.O. Box 360
Trenton, NJ 08625-0360
(888) 393-1062
www.state.nj.us/health/hcsa/hmocompl.pdf
For complaints
about business practices such as claims payment, member enrollment,
or termination of coverage contact:
NJ Department
of Banking and Insurance
Division of Enforcement and Consumer Protection
P.O. Box 329
Trenton, NJ 08625-0329
(800) 446-7467
www.state.nj.us/dobi/enfcon.htm
* The process
for appealing a decision or filing a complaint is different if
you belong to a “self-insured” plan. Check with your
employer or health plan.
Medicaid
To File a Medicaid Complaint
For information
on Medicaid health plan options, quality information and complaints,
call the New Jersey Department of Human Services at (800) 356-1561
or visit www.state.nj.us/humanservices.
Medicare
To File a Medicare Complaint
For information
on managed care options for Medicare in New Jersey, call the
New Jersey Department of Health and Senior Services, Division
of Senior Affairs, State Health Insurance Assistance Program
(SHIP) at (800) 792-8820 or call (800) MEDICARE. You can also
visit www.medicare.gov.
If you have a complaint about a Medicare managed care plan, refer
to your member services handbook for detailed information about
where to submit your complaint based on the type of complaint
you have.
Commercial
Health Care Insurance
To File a Health Plan Appeal
Your plan
is required to have an appeal process that gives you an opportunity
to resolve disagreements about denial of a covered benefit.
Preliminary
Stage
Review the services covered by your plan and the explanation
of the appeal process in the plan’s member handbook.
You or your doctor, acting with your consent, have the right
to file an appeal.
Stage
1
Inform the plan, either verbally or in writing, that you disagree
with the plan’s decision to deny or limit services you
believe are covered.
Stage
2
If you are dissatisfied with the results of the initial communication with
the plan, you can request, either verbally or in writing, that the plan have
your appeal reviewed by a panel of doctors and other health care professionals.
Stage
3
If you are dissatisfied with the plan’s decision on your Stage 2 appeal,
you can file an appeal with the Department of Health and Senior Services within
60 days of receiving the plan’s Stage 2 decision. You will receive the
form and instructions needed to file a Stage 3 appeal from your health plan
at the same time you receive the plan’s Stage 2 appeal decision. Your
case will be reviewed by independent experts under contract to the State through
the Independent Health Care Appeals Program (IHCAP). Decisions made by the
IHCAP are binding on the health plans.
For appeals
involving urgent circumstances, the plan is required to respond
within 72 hours in Stage 1 and 2.
Medicaid
Managed Care
To File a Medicaid Managed Care Appeal
If a covered
service is denied, terminated, reduced, or delayed by your Medicaid
MCO, you can file a request (verbally or in writing) for a Medicaid
Fair Hearing. Additionally, Medicaid Managed Care beneficiaries
may simultaneously use the managed care plan’s appeal
process.
Medicaid
Fee-for-Service
To File a Medicaid Fee-for-Service Appeal
You may file
a request for a Medicaid Fair Hearing with the Division of Medical
Assistance and Health Services (DMAHS) for the following issues:
denials of health care or payment for health care; access to
specialists; choice of health care provider; payment of health
care service you have received; access to prescription drugs;
and limitations or reductions in medically necessary health care
services.
Division of
Medical Assistance & Health Services
Office of Quality Assurance
P.O. Box 712
Trenton, New Jersey 08625-0712
Hotline: (800) 356-1561
Any time your
health plan makes a decision that denies, delays, or reduces
your Medicaid benefits, you have the right to written notice
explaining the action, which must be received at least 10 days
before any such action is taken. Moreover, upon your timely appeal
(not more than 10 days after the date of the notice), services
should stay until the final disposition of the appeal.
Medicare
Managed Care
To File a Medicare Managed Care Appeal
If you are
in a Medicare managed care plan, you can file an appeal if your
plan will not pay for, does not allow, or stops a service that
you think should be covered or provided. If you think your health
could be seriously harmed by waiting for a decision about a service,
ask the plan for a fast decision. The plan must answer you within
72 hours.
The Medicare
managed care plan must tell you in writing how to appeal. After
you file an appeal, the plan will review its decision. Then,
if your plan does not decide in your favor, the appeal is reviewed
by an independent organization that works for Medicare, not for
the plan. See your plan's membership materials or contact your
plan for details about your Medicare appeal rights.
If you have
concerns or problems with your plan which are not about payment
or service requests, you have a right to file a complaint. For
example, if you believe your plan's hours of operation should
be different, you can file a complaint.
Appeals
Process for Medicare Managed Care Plans
Non-Urgent
• You
need a service.
• Your
plan has 14 days to approve or deny.
• If
the plan denies service, you can file a standard appeal.
• The
plan has 30 days to respond to your standard appeal for service.
• If
the plan still says no, it must send your appeal to CHDR (Center
for Health Disputes and Resolution).
• CHDR
has 30 days to review your appeal.
• If
CHDR agrees with the plan to deny services, you can appeal the
decision to an Administrative Law Judge (ALJ) provided the amount
in dispute exceeds $100.00.
Urgent
• You
need a service urgently.
• Ask
you plan for an expedited (fast) decision or appeal.
• If
you ask for an expedited decision, the plan can refuse you. If
any doctor supports your request with a letter or phone call,
the plan must expedite your decision.
• If
the plan expedites, it must give you a decision within 72 hours
of your request.
• If
the plan still says no, it must send your appeal to CHDR.
• If
the plan does not expedite, it will make its decision using the
standard appeals process.
• You
can also file a grievance with your plan for not providing an
expedited response. Send a copy of your grievance to CMS, the
federal agency that administers Medicare, and your local Senator
and Congressperson.
Further
levels of appeal:
• Department
Appeals Board.
• Federal
Court – must be at least $1,000 in dispute.
Medicare
Fee-for-Service
To File a Medicare Fee-for-Service Appeal
If you are
enrolled in the Original Medicare Plan, you can file an appeal
if you think Medicare should have paid for, or did not pay enough
for, an item or service you received. If you file an appeal,
ask your doctor or provider for any information related to the
bill that might help your case. Your appeal rights are on the
back of the Explanation of Medicare Benefits or Medicare Summary
Notice that is mailed to you from a company that handles bills
for Medicare. The notice will also tell you why your bill was
not paid and what appeal steps you can take.
Denial
Notice
You get a
notice of denial of payment or service, and you disagree with
it.
Reconsideration
Send the denial
notice back to Medicare with a “please review” note.
Try to add supporting information from your doctor.
Fair
Hearing (Part B Only)
Request a
fair hearing if you do not agree with the Reconsideration decision.
• There must be at least $100 in dispute.
Administrative
Law Judge (ALJ) Hearing
You can appeal
to an ALJ if you disagree with Medicare’s Reconsideration
of your Part A claim, or with the Fair Hearing decision (Part
B).
• There must be at least $100 in dispute (Part A).
• There must be at least $500 in dispute (Part B).
Departmental
Appeals Board (DAB)
You can appeal
to the DAB if you disagree with the ALJ decision. The DAB, at
its discretion, may review your case if it disagrees with the
ALJ decision.
Appeal
to Federal Court
To appeal
to federal court:
• There must be at least $1,000 in dispute.
Self-Funded/Self-Insured
Plans
To File a Self-Funded/Self-Insured Plan Appeal
Large employers
and unions often assume financial responsibility for employee
health benefits instead of buying insurance. Employers may contract
with outside organizations to administer their self-insured health
benefits plan. These plans are not bound by our state’s
statutory or regulatory requirements but rather, by federal
rules. Roughly half of all New Jerseyans getting health benefits
through their employers are in self-insured plans. Questions
or complaints about these self-insured plans can only be addressed
by the federal Department of Labor’s Pension and Welfare
Benefits Administration. The main number is (866) 275-7922. The
web site is www.dol.gov/dol/pwba.
Helpful
Tips to Better Understand Your Health Plan
Quality
of Care and Services
• Look
to see how well the plan performs in each section of this report.
• Pay
special attention to the health issues that are most important
to you and your family.
• Do
not focus on small differences in a single measure that may not
be meaningful. When comparing plans, look at all the factors
that contribute to a health plan’s performance and at large
differences in the measures.
Choice
of Providers
• Make
sure that your preferred doctor, hospital and other providers
participate in the plan by looking in the plan’s directory.
You should also call the plan’s member services department
or the provider directly.
• Decide
whether the plan has enough of the kinds of doctors you are likely
to need and whether they are located near your home or work.
• Once
you have selected a provider, make sure the doctor has office
hours and a location convenient for you and your family.
Benefits
• Find
out what types of benefits the plan offers by reviewing the member
handbook or calling the member services department.
• Consider
your special needs and circumstances such as chronic health conditions,
elder care, frequent travel, language, retirement and family
planning.
• Decide
whether there is a good match between the benefits offered by
the plan and what you think you may need.
• Find
out what types of care or benefits the plan does not offer.
Costs
• Try
to get an idea of how much you are likely to pay in premiums,
copayments, coinsurance and deductibles each year.
• Find
out if the plan covers services by providers outside the network
and how much it will cost you for these services.
• See
if there are any limits on how much you are responsible for paying
in case of major illness (out-of-pocket maximum).
• Find
out if the plan places limits on the amount of benefits it will
pay (annual or lifetime maximum).
Accreditation
NCQA, also
know as the National Committee for Quality Assurance, is a non-profit
organization committed to assessing, reporting on and improving
the quality of care provided by the nation’s health plans.
To find out if your health plan is NCQA accredited, call toll-free
(888) 275-7585 or visit their web site at www.ncqa.org.
URAC, also
known as the American Accreditation HealthCare Commission, is
a non-profit organization originally focused on the accreditation
of utilization review programs. URAC now provides accreditation
services for many types of health care organizations, including
HMOs. For information on URAC’s accreditation services,
visit their web site at www.urac.org.
JCAHO, the
Joint Commission on Accreditation of Healthcare Organizations,
is an independent, not-for-profit organization that evaluates
and accredits various types of health care networks including
health plans, hospitals, home health care organizations and others.
For more information on JCAHO’s accreditation services,
visit their web site at www.jcaho.org.
Getting involved
in your health care can help you get the most from your health
plan.
Know
the Rules
• Understand
what services your plan does and does not cover by reading the
member handbook or talking to your employer.
• Know
how to choose or change your primary care physician.
• Understand
how to schedule appointments for check-ups and when you are sick.
• Know
when you need referrals and how to get them.
• Know
what you are required to do when using a hospital or emergency
room.
Stay Informed
• Be
sure to learn about any new policies affecting how the plan works
by reading member newsletters and checking the plan’s web
site.
• Know
the telephone numbers and hours of your physician’s office
and the plan’s member services department.
Keep Records
• Write
down your health concerns to help you discuss them with your
doctor.
• Set
up health files to keep track of the care and services received
by you and members of your family.
Take Charge
• Take
good care of your health by making appointments for check-ups
and preventive care.
• Talk
with your doctor about when you need regular health screenings.
• Call
member services if you do not understand information that the
plan or provider sends you.
• If
you do not understand the answers to your questions, ask that
they be explained to you.
Choose a Doctor Carefully
• Ask
for recommendations from medical societies, health care providers,
referral services, hospitals, family members and friends.
• Get
information about the doctor’s training and experience
from the plan or the doctor.
• Ask
if the doctor is board certified in his or her specialty area.
• Check
whether prospective doctors have had any disciplinary actions
issued against them.
Information,
in part, from the 2002 New Jersey HMO Performance Report.
