Utilization Management Members’ Appeals Process
- Horizon NJ Health has developed and implemented appeal policies to receive and adjudicate utilization management appeals made by members or health care professionals acting on behalf of members with the member’s documented consent.
- This procedure will ensure timely resolution, be easily accessible and provide prompt, fair and full investigation of member appeals.
- A member or health care professional acting on behalf of a member with the member’s documented consent may submit an appeal within 90 days of receiving a denial letter for a dental or orthodontic procedure or out of network provider. Hospitals may obtain consent from the covered person prior to receiving hospital services. The consent is valid for all stages of internal and external appeals. Patients may revoke consent at any time. Members can verbally appeal adverse utilization management determinations.
- All appeals from a physician must be submitted with a written signed consent from the member except when the request is for an expedited resolution.
- Physicians and/or all other health care professionals must provide the covered person notice of an appeal whenever an appeal is initiated and again each time the appeal is continued to the next stage, including any appeal to an IURO. All written appeals must be submitted to the following address:
Horizon NJ Health Appeals | Unit P.O. Box 295 | Milwaukee, WI 53201
- A member may also make an appeal or grievance by contacting Member Services at 1 (877) 765-4325 for assistance with writing the appeal.
Complaint Resolution for Members and Health Care Professionals
The procedure for initiating a complaint is outlined below:
- When a member or health care professional is dissatisfied with care or service received, a complaint can be initiated by: • Calling a Horizon NJ Health Customer Service Representative. 1 (877) 765-4325 for members and 1 (800) 682-9091 for dentists.
- Submitting a written complaint to: Scion Dental Complaints Department Milwaukee, Wisconsin 53201
- Submitting a verbal or written request directly to the Department of Banking and Insurance via telephone, fax or online complaint to: Department of Banking and Insurance (DOBI) 20 West State Street | P.O. Box 325 Trenton, NJ 08625 1 (800) 446-7467 www.state.nj.us/dobi
- The provider/complainant will be notified in the following timeframes: Urgent cases including verbal notification will be addressed within 48 hours.
- Complaints resolved within five business days will receive verbal notification of the outcome from a Complaints Coordinator. If Horizon NJ Health is unable to reach the initiator of the complaint through a telephone call, written notification including the outcome will be sent within 30 days.
- Complaints not resolved within five business days will receive written notification including the outcome within 30 days. Complaints not resolved within five business days will be considered a grievance.
- All members and health care professionals will be informed of their right to appeal either verbally or in the written notification within 90 days of the resolution. No penalty will be taken against a member or health care professional for filing a complaint/grievance or subsequent appeal. Fair Hearing Procedures, including the Medicaid enrollee’s right to access the Medicaid Fair Hearing process, is also included in the verbal and/or written notification.
- The complaint/grievance is considered resolved unless an appeal is requested.