Section 6 - Grievance and Appeals Process
Grievance/Appeals Process for MLTSS Providers
Horizon NJ Health has a system and procedure for the resolution of grievances by providers. The grievance procedure is available to all providers; timely resolution will be executed as soon as possible and will not exceed 48 hours from initiation of the grievance for urgent cases and 30 days for all other issues.
The procedure for initiating a grievance is outlined below:
- When a provider is dissatisfied, a grievance can be initiated through any of the following:
- Call a Provider Services representative at 1-800-682-9091
- Send a written letter to:
Horizon NJ Health
PO Box 24077
Newark, NJ 07101-0406
- Inform any Horizon NJ Health staff member within any department that you wish to file a formal grievance
- Submit a verbal or written request directly to the Department of Banking and Insurance, via phone call, fax or complaint form
- Once received by the appropriate representative, efforts will be made to resolve the grievance.
- If you are not satisfied with the resolution offered by the representative, you should request that a formal grievance be filed.
- A grievance resolution analyst will investigate the grievance, and you will be notified within the following timeframes:
- Urgent cases, including verbal notification, will be addressed within 48 hours
- Those grievances resolved within five business days will receive verbal notification of the outcome from the resolution analyst. If Horizon NJ Health is unable to reach the initiator of the grievance through a phone call, a written notification that includes the outcome will be sent within 30 days
- Unless an appeal is requested, the grievance is considered to be satisfactorily resolved.
- Horizon NJ Health investigates all grievances and alleged incidents reported by or related to our members, which may include, but not limited to:
- Phone call to the health care practitioner or facility by Provider Contracting & Servicing to clarify the circumstances of the grievance
- Request for medical records and/or a written response from the health care practitioner or facility, which is due within 10 calendar days
- Site visit
- Within the grievance process, a vital part of the resolution is the assistance of a health care practitioner or facility. Using the information from the member and provider, all grievances are thoroughly investigated. After all the information is gathered, a medical director makes a determination if there is a quality issue.
- For provider grievances related to administrative issues, quality of care, actions, sanctions or terminations, refer to Section 8.29 and Section 8.30.
MLTSS Member Grievance and Appeals Process
Horizon NJ Health has a grievance procedure for resolving disagreements between members, providers and/or Horizon NJ Health. Disputes may involve our benefits, the delivery of services or our operation. This procedure includes both medical and non-medical (dissatisfaction with the Plan of Care, quality of member services, appointment availability, or other concerns not directly related to a denial based on medical necessity) issues. A grievance, by phone or in writing, can usually be resolved by contacting Member Services.
A member may file a grievance and/or appeal in his or her primary language. All steps of the process shall be in his or her primary language, including the notification of the grievance and appeal rights and the decision of the appeal.
Issues regarding emergency care will be addressed immediately. Issues regarding urgent care will be addressed within 48 hours in the member’s primary language. Horizon NJ Health will not discriminate against a member or attempt to disenroll a member for filing a grievance or appeal.
A member who is not satisfied with the supports and services he or she is receiving should call his or her Care Manager right away. The Care Manager will work with the member and his or her service agencies to try and fix the problem. At times it may be appropriate to contact Member Services at 1-844-444-4410 (TTY 711) for help in resolving the grievance or problem.
Filing a Formal Grievance
If a member feels that neither his or her MLTSS Care Manager nor the Member Advocate has resolved his or her issue, the member can file a formal grievance in two ways: either verbally or in writing. The member can call Member Services toll free at 1-844-444-4410 (TTY 711), and speak to a representative.
A written grievance can be mailed to:
Horizon NJ Health
PO Box 24077
Newark, NJ 07101-0406
A member can also contact the Department of Banking and Insurance at 1-609-292-5316 or submit a grievance form.
A member or his or her provider, with the member’s written approval, has the right to ask Horizon NJ Health to review and change our decision if we have denied or reduced the member’s benefits. This is called an appeal. An appeal can be oral or written. All appeals must be submitted within 60 days of the date of the denial notification.
The appeal process is described below. A member also has the right to ask Medicaid to review Horizon NJ Health’s decision about services. This is called a Fair Hearing.
Utilization Management Appeals Process
Horizon NJ Health has appeals policies to receive and adjudicate utilization management appeals made by members and providers. This procedure ensures timely resolution, provides easy access and offers prompt, fair and full investigation of UM appeals.
The appeal procedure is as follows:
In the case of an enrollee who was receiving a service (from the Contractor, another Contractor, or the Medicaid Fee-for-Service program) prior to the determination, the Contractor shall continue to provide the same level of service while the determination is in appeal.
Horizon Medical Appeals
PO Box 10194
Newark, NJ 07101
You can also request an appeal by calling our UM Appeals Department at 1-800-682-9094 x89606 or by fax at 1-609-583-3028.
Actions that can be appealed include but are not limited to:
- Any member or provider may appeal any UM decision resulting in a denial, termination, or other limitation in the coverage of and access to health care services. Horizon NJ Health must inform the member and provider of its decision using the Notice of Action template letters developed and provided by the state. These template letters explain the appeal process upon the notice of action and at the conclusion of each stage in the appeal process. Members and providers will be given a written explanation of the appeal process upon the conclusion of each stage in the appeal process.
- A member or provider, acting on behalf of a member and with the member’s documented consent, may request an appeal by contacting the UM Appeals Department. All written appeal requests must be submitted to the following address:
- All appeals (regardless of level or type) must include the following information:
- Name, address and number (if applicable) of the member(s) and/or physician(s) making the appeal
- Member ID number
- Date(s) of service
- Name(s) of physician, vendor or facility
- Specific details regarding the actions in question
- The nature and reasoning behind the appeal
- The desired outcome
- Supporting documentation, e.g., medical record
Actions that can be appealed include but are not limited to:
- An adverse determination under a utilization review program
- Denial of access to specialty and other care
- Denial of continuation of care
- Denial of a choice of provider if based on medical necessity
- Denial of access to needed drugs
- The imposition of arbitrary limitation on medically necessary services
- Denial, in whole or in part, of payment for a benefit if based on medical necessity
- Denial or limited authorization of a requested service, including the type or level of services
- The reduction, suspension or termination of a previously authorized service
- Failure to provide services in a timely manner
- Denial of a service, based on lack of medical necessity
Continuation of Benefits During UM Appeals and IURO Appeals
Horizon NJ Health will continue services automatically during Internal and External Independent Utilization Review Organization (IURO) appeals if all of the following conditions are met:
- Appeal is filed timely
- The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment
- Services were ordered by an authorized provider
- Appeal request is made on or before the final day of previously approved authorization, or within 10 calendar days of the notification of adverse benefit determination, whichever is later. (A later request – one taking place after an interruption – will not constitute a continuation of benefits. An appeal request can still be made after this point – up to 60 days from the notice of adverse determination – but it will not include continued benefits.)
- If the above criteria are not satisfied, the member will not be eligible for continuation of benefits.
NOTE: Horizon NJ Health will notify the member and provider at least 10 days in advance of the termination, suspension or reduction of a previously authorized course of treatment. If we fail to meet this deadline, we will extend the original authorization (and the member’s timeframe to request continued benefits) to a date 10 days after the date of notification.
Internal appeals are reviewed by health professionals who are clinical peers; hold an active, unrestricted license to practice medicine or a health profession; are board certified (if applicable) by a specialty board approved by the American Board of Medical Specialties (doctors of medicine) or the Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine); are in the same profession and in a similar specialty that typically manages the medical condition, procedure or treatment, as mutually deemed appropriate; and are neither the individual who made the original noncertification, nor the subordinate of such an individual.
Urgent or emergent appeals determinations, including verbal and written notification, shall be completed as soon as possible and will not exceed 72 hours after the initiation of the appeal request. Non-urgent and non-emergent internal utilization management appeal determinations, including written notification, shall be completed within 30 calendar days.
If the appeal is not resolved to the member’s satisfaction, Horizon NJ Health will provide a written explanation of how to proceed to an External appeal. All Adverse Determination letters will document the clinical rationale for the decision, including a statement that the clinical rationale used in making the appeal decision will be provided in writing upon request. A member or physician acting on behalf of a member with the member’s documented consent can obtain, upon request, reasonable access to and copies of all documents relevant to the appeal.
External Appeal – IURO
Following an adverse determination for an Internal Appeal, the External appeal process includes filing an appeal with the Independent Utilization Review Organization (IURO) assigned by the New Jersey Department of Banking and Insurance (DOBI). Send External appeal requests to:
New Jersey Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 329
Trenton, NJ 08625-0329
Phone: 1-888-393-1062 (option 3)
External appeals must be filed with the IURO within 60 days of the adverse Internal appeal determination.
The request must be filed on the application for the Independent Health Care Appeals Program form. The request should be accompanied by the specified fee and general release, executed by the member, for all medical records pertinent to the appeal, as indicated on the form.
Upon receipt of the request to review an appeal from DOBI, the IURO will conduct a preliminary review of the appeal and accept for processing if it determines that:
- The individual was a covered person of Horizon NJ Health at the time of the action on which the appeal is based.
- The service, which is subject to the appeal, reasonably appears to be a covered service under the terms of the contract between the covered person and Horizon NJ Health.
- The member, or provider acting on behalf of the member with the member’s consent, has provided all information required by the IURO and DOBI to make the preliminary determination. This information includes the IURO appeal form and a copy of any information provided by Horizon NJ Health regarding the decision to deny, reduce or terminate the covered service and a fully executed release to obtain any necessary medical records from Horizon NJ Health and any other relevant health care provider.
Upon completion of the preliminary review, the IURO notifies the covered person and/or provider in writing if the appeal has been accepted for processing and if not, the reason(s) why, within five business days of receipt of the request. The External appeal process is administered by DOBI and is utilized for the review of the appropriate utilization and medical necessity of covered health care services. The services below may not be eligible for the DOBI External appeal process.
- Adult Family Care
- Assisted Living Program
- Assisted Living Services – when the denial is not based on medical necessity
- Caregiver/Participant Training
- Chore Services
- Community Transition Services
- Home-Based Supportive Care
- Home-Delivered Meals
- Personal Care Assistance
- Respite (Daily and Hourly)
- Social Day Care
- Structured Day Program – when the denial is not based on medical necessity
- Supported Day Services – when the denial is not based on the diagnosis of TBI
Upon acceptance of the appeal for processing, the IURO shall conduct a full review to determine whether, as a result of our UM determination, the covered person was deprived of medically necessary covered services. In reaching this determination, the IURO will take into consideration all information submitted by the parties and information deemed appropriate in the opinion of the IURO, including pertinent medical records; consulting physician reports and other documents submitted by the parties; any applicable, generally accepted practice guidelines developed by the federal government; national or professional medical societies, boards and associations; and any applicable clinical protocols and/or practice guidelines developed by Horizon NJ Health.
The IURO shall refer all appeals to an expert physician in the same specialty or area of practice who would generally manage the type of treatment that is the subject of appeal. All final decisions of the IURO shall be approved by a medical director of the IURO, who is a physician licensed to practice medicine in the state of New Jersey. The IURO does not have any direct financial interest in the organization or outcome of the independent review.
The IURO shall complete its review and issue a decision as soon as possible in accordance with medical exigencies of the case. Standard appeals must be completed within 45 calendar days and expedited appeals must be completed within 48 hours.
Once the IURO renders a determination, the decision is binding on Horizon NJ Health and the member, except to the extent that other remedies are available to either party under state or federal law. The IURO will send a written notification of the decision. The decision will be acknowledged in writing by Horizon NJ Health. If the IURO overturns an adverse determination resulting from an Internal appeal, we will reprocess the payment (if previously processed) within 10 business days.
External Appeal - Fair Hearing
Only NJ FamilyCare A and NJ FamilyCare ABP members have access to the Fair Hearing Process. Members or providers, acting on behalf of members with the members’ written consent, can request a Fair Hearing within 120 days from the date of the notice of action letter following an adverse determination resulting from an Internal appeal. The internal appeal must be completed prior to a request for a Fair Hearing.
A member has the right to pursue a Fair Hearing after the completion of, in lieu of, or concurrently with an External IURO Appeal. Members enrolled in NJ FamilyCare B, C or D do not have the right to request a Fair Hearing. Those members only have access to Internal and External IURO appeals. Members of these plans have up to 60 days after the adverse determination to file an Internal appeal and, if that is denied, up to 60 days to file an External appeal.
Continuation of Benefits during a Fair Hearing
Although a member has up to 120 days to request a Fair Hearing, he or she must request continuation of benefits during a Fair Hearing within the following timeframes:
- Within 10 calendar days of the notice of action letter following an adverse determination resulting from an Internal Appeal (if he or she wishes to pursue a Fair Hearing concurrently with or instead of an External/ IURO appeal)
- Within 10 calendar days of the notice of action letter following an adverse determination resulting from an External/IURO appeal, or on or before the final day of the previously approved authorization, whichever is later
If the member did not qualify for a continuation of benefits during a UM Appeal or an IURO Appeal, then the member will not qualify for a continuation of benefits during a Fair Hearing. If the Fair Hearing results in an outcome that is not in favor of the member, he or she may be required to pay for the cost of the services that were provided during the continuation of benefits. If Horizon NJ Health does not cover the services while the Fair Hearing is pending, and the Fair Hearing results in a decision to reverse the adverse determination, we will cover the services that were not furnished. If the Fair Hearing results in a decision to uphold the adverse determination, we will still pay for the services that were provided during the continuation of benefits.
Claim Appeals Process
This section describes procedures through which participating and nonparticipating providers, facilities and health care professionals have a right to a written appeal of disputes relating to payment of claims, as defined below. As always, Horizon NJ Health’s procedures are intended to provide our providers, facilities and health care professionals with a prompt, fair and full investigation and resolution of claims issues. The procedure includes a Stage Two external Alternative Dispute Resolution (ADR) option for claim payments that providers, facilities and health care professionals can continue to dispute after pursuing their appeal through Horizon NJ Health’s Stage One internal claims appeal process.
Common Appeal Reasons
- No Authorization: Authorization was provided by provider or Horizon NJ Health prior to providing the service to the member.
- Untimely Filing: Claim was filed within the required 180 days from the date of service.
- Payment Discrepancy: The amount paid was inconsistent with the contracted rate or the established Horizon NJ Health fee schedule.
- Member Not Enrolled: The member was enrolled in the Medical Assistance program on the date of service, as evidenced by valid source documentation.
- Lack of EOB: Third party liability information has been provided to show the member is not eligible for other coverage or has reached his or her benefit limit.
- Claims Editing Discrepancy: Provider, facility or other health care practitioner disagrees with the edits applied to the claim.
- Incorrect Denial: The denial code on the claim is not accurate.
No provider, facility or health care professional who exercises the right to file an appeal under this procedure shall be terminated or otherwise penalized for filing and pursuing such an appeal.
When a provider, facility or health care professional is dissatisfied with a claim payment, including payment determinations, prompt payment or no payment made by Horizon NJ Health, he or she may file a claim appeal, as described herein. All claim appeals must be initiated on the applicable appeal application form created by DOBI. We must receive the appeal within 90 calendar days following receipt by the provider, facility or health care professional of the payer’s claim determination.
To file a claim appeal, a health care professional must mail the appeal application form and any supporting documentation to Horizon NJ Health at the following address:
Claims Appeals Coordinator
Horizon NJ Health
PO Box 63000
Newark, NJ 07101-8064
IMPORTANT – Please do not send medical records with administrative claim appeals. Supporting documentation, i.e., proof of timely filing, may be submitted. Please follow all appropriate procedures as defined in this Manual before submitting an appeal.
A Horizon NJ Health employee who serves as an appeals resolution analyst will review all claim appeals. Appeals resolution analysts are personnel of Horizon NJ Health who are not responsible on a day-to-day basis for the payment of claims. The appeals resolution analyst shall review all submitted documentation and confer with all necessary departments, given the nature of the claim appeal. Upon review by the appeals resolution analyst, a decision will be rendered. The appeals resolution analyst will render a final determination with written notification that will be sent to the facility or health care professional within 30 calendar days of the date of our receipt of the claim appeal request. The appeal decision will be sent to the contact information that is documented on DOBI’s Claim Appeal Application Form.
Horizon NJ Health has established a binding and non-appealable external alternative dispute resolution (ADR) mechanism that involves arbitration and, in some cases, mediation, for facilities or health care professionals who remain dissatisfied following their pursuit of an appeal through the Stage One internal claim appeal process. These mechanisms are described below.
Alternative Dispute Resolution (ADR)
All adverse decisions made by a claim appeal reviewer may be appealed by the health care professional through an independent, binding ADR process. Arbitration must be initiated on or before the 90th calendar day following receipt of the determination of an internal appeal.
Disputes must be in the amount of $1,000 or more. Health care professionals may aggregate claims to reach the $1,000 minimum under circumstances in which the same claim issue is involved.
DOBI awarded the independent arbitration organization contract to MAXIMUS, Inc. Parties with claims eligible for arbitration may complete an application and submit the application, together with required review and arbitration fees, to the Program for Independent Claims Payment Arbitration (PICPA).
Participating and nonparticipating health care professionals may initiate the above binding and non-appealable external ADR review of an adverse decision of a physician or health care professional claim appeal review after the Stage One internal appeal by filing a request for external ADR review with the written findings from the Stage One determination within 90 calendar days from the date of the claim appeals reviewer’s written decision to the following address:
Attn: New Jersey PICPA 3750 Monroe Ave.
Pittsford, NY 14534
External appeals must be initiated through MAXIMUS, Inc., and not through Horizon NJ Health. Further information regarding the Program for Independent Claims Payment Arbitration (PICPA) can be found on MAXIMUS’s website or on the DOBI website.
Notwithstanding of the above, providers have the right, at any time and regarding any issue, to seek assistance from the following:
New Jersey Department of Health and Senior Services
Office of Managed Care
PO Box 367
Trenton, NJ 08625-0367
New Jersey Department of Banking and Insurance
Division of Enforcement and Consumer Protection
PO Box 329
Trenton, NJ 08625-0329