For Providers

Utilization Management

Utilization Management Appeal Process for Administrative Denials
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1. PURPOSE
To provide and govern an appeals procedure that defines the appeal process for administrative denials for inpatient and outpatient services.

2. SCOPE AND APPLICABILITY
This policy was developed in accordance with applicable Centers for Medicare and Medicaid Services (CMS) guidelines, the NJ Medicaid Managed Care Contract, applicable NJ State and Federal Guidelines, and national accreditation standards. This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines.

  1. This policy applies to NJ FamilyCare/Medicaid

3. POLICY
Utilization management has established policies that provide governance over submission of clinical information for review for an authorization. The following polices set forth the administrative rules and timeframes for submission of requests for authorization of services:

  • 31C.030 Retrospective Review Policy
  • 31C.537 Utilization Management Submission and Determination Timeframes
  • 31C.001 Prior Authorization of Medical Services

In the event the provider or member is appealing for a service that has already been provided, required prior authorization or concurrent review, and the timeframe for a retrospective authorization has passed, the appeal will not be reviewed for medical necessity. Instead the appeal will be reviewed pursuant to the UM policy that was used to make the initial determination.

4. DEFINITIONS
Administrative Denial: Denials of coverage of services or supplies based on reasons other than clinically based rationale which does not require medical director review.

5. SANCTIONS
Horizon NJ Health may be subject to the Sanctions and/or Liquated Damage Provisions of the Medicaid Contract. Specifically, Articles 7.15 and 7.16

6. EXCEPTIONS
As defined in the UM policies referenced herein.