48horizonNJhealth.com47 Member Services: 1-800-682-9090

It is very important that you take personal
responsibility for your health care and the costs
of your care. Make sure you know as much as
possible about the doctors you use and the
treatments they provide.

Billions of dollars are lost to health care fraud,
waste and abuse each year. That means money
is paid for services that may never have been
given. It could also mean that the service that
was billed was not the one performed. Fraud,
waste and abuse by doctors and members
threaten our health care system and can
victimize consumers.

What is Fraud, Waste and Abuse?
Fraud and abuse happen when someone
knowingly gives false information that lets
someone get a benefit they are not entitled to.

Examples of Doctor Fraud, Waste and Abuse
? Forging or altering bills or receipts

? Billing for services that were not performed

? Giving a patient a false diagnosis to justify
tests, surgeries or other procedures that
are not medically necessary

? Billing more than once for the same service

Examples of Member Fraud, Waste and Abuse
? Telling a lie on purpose that results in you

or another person receiving benefits that
you or they are not entitled to

? Loaning or selling your Horizon NJ Health
member ID card or the information on the
card to someone else

? Forging or altering prescriptions

Misuse of your Horizon NJ Health ID card
could result in you losing eligibility for health
care services. Fraud and abuse are also crimes
punishable by legal action with possible time
in jail.

If you or someone you know is aware of health
care fraud, waste and abuse, you should
immediately report it to Horizon NJ Health?s
Fraud Hotline at 1-855-FRAUD20
(1-855-372-8320) (TTY 711), or the New Jersey
Medicaid Fraud Division at 1-888-937-2835
(TTY 1-877-294-4356).
When making a report, please be clear about
which person you believe is committing the
fraud, tell us dates of service or items in
question, and describe in as much detail as
possible why you believe fraud may have been
committed. If possible, please include your
name, telephone number and address so we
can contact you if we have questions during the
investigation.

Any information you give us will be treated with
strict confidentiality and no medical information
will be released without lawful authorization.
When reporting suspected insurance fraud, you
do not have to give your contact information. If
you decide to give your contact information, we
will try to keep it confidential as much as legally
possible.

Horizon NJ Health has a grievance procedure
for resolving disagreements between members,
providers and/or Horizon NJ Health?s operation
or any cause of member dissatisfaction. Upon
request, the notification of grievance and appeal
rights shall be in your primary language. You may
file your grievance and/or appeal in your primary
language. You will also receive the decision
in your primary language. Issues regarding
emergency care will be addressed immediately.
Issues regarding urgent care will be addressed
within 48 hours in your primary language.
Horizon NJ Health will not discriminate against
a member or attempt to disenroll a member for
filing a grievance or appeal.

Grievance Procedure
A grievance can be filed by phone or in writing
and can usually be resolved by contacting
Member Services. If you have a grievance, call
1-800-682-9090 (TTY 711), to talk about it with
one of our Member Services representatives. If
you want, you may send a written grievance to:

Grievances Department
1700 American Blvd.
Pennington, NJ 08534

A dental grievance can be filed by calling
1-855-878-5371 (TTY 1-800-508-6975). The
Dental Operations group will handle all dental
grievances and send you a letter with the
outcome.

When we receive your call or letter, the
following steps will occur:
1. If you call to file a grievance, a Member

Services representative will be available to
discuss and help resolve your grievance.
During this call the Member Services
representative will make every attempt to
resolve your grievance.

? If you are not satisfied with the
resolution from the Member Services
representative during your call, tell the
representative and the grievance will
be forwarded to Horizon NJ Health?s
Complaint Resolution Analyst for further
investigation.

? The Complaint Resolution Analyst will
investigate the grievance and you will
get a written notification about the
outcome within 30 days of receipt of the
grievance.

2. If you submit a written grievance by mail,
a Complaint Resolution Analyst will try to
contact you by telephone within 24 hours
of receipt of the grievance to discuss
and assist in resolving your grievance.
The Complaint Resolution Analyst will
document all the information discussed
with you in our complaint tracking system.
An investigation will begin immediately.

? Written grievances are to be resolved as
required by the urgency of the situation,
but no later than 30 days after receipt.
Once complete, you will receive a
written notice with final outcome within
30 days of receipt of the grievance.

Fraud, Waste and Abuse Grievance and Appeal Procedures



50horizonNJhealth.com49 Member Services: 1-800-682-9090

Appeals
You or your doctor (with your written approval)
have the right to ask Horizon NJ Health to review
and change our decision if we have denied or
reduced your benefits. This is called an appeal.
An appeal can be oral or written. Appeals
filed orally must be followed up with a written
request. All appeals must be submitted within
60 days of the date of the denial letter. Please
follow the appeal process described below.

You also have the right to ask the State to
review Horizon NJ Health?s decision about
your service. This is called a Fair Hearing. You
have this benefit if you are a NJ FamilyCare A
or Alternative Benefit Plan (ABP) member. Call
Horizon NJ Health at 1-800-682-9090 (TTY 711)
to ask if you are eligible. You may request a Fair
Hearing following the completion of an Internal
Appeal. However, the timeframe to request a
Fair Hearing in writing is within 120 days from the
date of the notice of adverse decision following
the Internal Appeal of a denial determination.

If you wish to appeal home care benefits, such as
Personal Care Assistance (PCA), administered by
the Personal Preference Program, please use the
Fair Hearing process, after the Internal Appeal
decision, explained on page 51.

Appeal Process
The appeal process consists of an Internal
Appeal completed by Horizon NJ Health.
Horizon NJ Health will review its decision about
the services you asked for. If you are not happy
with our decision at the end of the Internal
Appeal or if Horizon NJ Health?s decision was
not made by the deadline set, you may ask to
have your request reviewed by someone outside
of Horizon NJ Health. This is an External Appeal.

During the appeal process, you have the right to
continue to get the Horizon NJ Health service in
question until the end of the process if:

? Your appeal is filed in a timely fashion

? The service was previously approved by
Horizon NJ Health and the appeal involves
the termination, suspension or reduction of
that service

? The service was ordered by an authorized
provider

? The appeal request is made on or before
the final day of the previously approved
authorization, or within 10 calendar days
of the notification of adverse benefit
determination, whichever is later

In the event that Horizon NJ Health fails to meet
its obligation to send the notification of adverse
benefit determination at least 10 calendar
days prior to the final day of the previously
approved authorization, Horizon NJ Health shall
automatically extend the authorization to a date
10 calendar days after the date on which the
notification was sent.

You may ask for a copy of the benefit provision,
guideline, protocol or other criterion on which
the appeal decision was based. Horizon
NJ Health will provide the medical records
relating to the determination.

Internal Appeal
Your Internal Appeal must be started no later
than 60 days after the date of the denial letter
sent to you. You or your doctor must:

? Call Horizon NJ Health toll free at
1-800-682-9094 (TTY 711). Oral requests
for an appeal must be followed up in
writing, or

? Fax your letter to the Appeals department
at 1-609-583-3028, or

? Send us a letter to:
Horizon Medical Appeals
PO Box 10194
Newark, NJ 07101

Let us know:
1. Your name and Horizon NJ Health

ID number

2. Your doctor?s name

3. That you want to appeal our decision

4. The reason you want to appeal

5. If the services are for urgent or emergency
treatment

Horizon NJ Health must get back to you with a
decision within 30 calendar days. If your appeal
is about services for urgent or emergency
treatment, we will tell you the results of your
appeal within 72 hours (three days ? weekends
and holidays count).

If we do not approve the services you are asking
for in your appeal, Horizon NJ Health will send
you a letter and explain why. We will also tell you
how to file an External Appeal.

Dental Internal Appeals
If you disagree with Horizon NJ Health?s
decision, you (or your provider, with your written
consent) have a right to appeal this action. You
have a right to appeal through Scion Dental?s
Internal Appeal process. You also have the
option to appeal to the Independent Utilization
Review Organization (IURO). NJ FamilyCare A
and ABP members have the right to request
a Fair Hearing. You must follow the following
Internal Appeal Process.

Health Plan Internal Appeal Process:
You can file an Internal Appeal by:

1. Calling Scion Dental at 1-855-878-5371
(TTY 1-800-508-6975); AND

2. Writing to Scion Dental at PO Box 295,
Milwaukee, WI 53201.

If you call first, you must follow-up your
phone request by writing to Scion Dental at
the address in #2 above.

In your letter, you should include an explanation
for the reason you are appealing our decision
and then sign your request for an appeal. You
have 60 calendar days from the date on which
the notification was sent to request an Internal
Appeal.

However, if you are now receiving these services,
and you want these services to continue
automatically during the appeal, you must either
request an Internal Appeal on or before the final
day of the previously approved authorization, or
request an Internal Appeal within 10 calendar
days from the date on which the notification was
sent, whichever is later.

If you do not request your appeal within these
timeframes, the services will not continue during
the appeal. Scion Dental will decide your Internal
Appeal within 30 calendar days of receipt of your
appeal.

If you or your treating provider believe this
30 calendar-day timeframe for deciding your
appeal is too long and could harm your health,
please call Scion Dental at 1-855-878-5371
(TTY 1-800-508-6975) and ask for an expedited,
or fast appeal. An expedited or fast appeal
means that Horizon NJ Health will decide your
Internal Appeal within 72 hours of receipt. You
may ask for an expedited, or fast appeal, if
you are an inpatient in a facility, if the care you
received was for an urgent or emergency health
concern or if it is medically necessary and taking
30 calendar days to decide the appeal could
seriously harm you in some way.

If you call to request an expedited, or fast
appeal, you do not have to follow up your
phone call with a written request.

Grievance and Appeal Procedures (continued)



52horizonNJhealth.com51 Member Services: 1-800-682-9090

Grievance and Appeal Procedures (continued)
External Appeal
If you want to appeal the denial of your Internal
Appeal, you may ask that someone outside
of Horizon NJ Health review your request
for service. This is done by an Independent
Utilization Review Organization (IURO). Within
60 days of the date of Horizon NJ Health?s
written notice of the internal appeal decision,
you or your doctor must:

? Fill out the form called Application for the
Independent Health Care Appeals Program,
sent to you with the results of your Internal
appeal decision from Horizon NJ Health. Be
sure to sign the form. Your signature allows
the IURO to review your medical records
and other medical information that may be
needed for your appeal.

The IURO will give you its decision within 45 days
after it gets all the materials it needs to make
a decision. You may present your information
about your case directly to the Appeals
Committee either in person or by telephone.
You may have someone come with you to the
proceedings.

If your appeal is about services for urgent or
emergency treatment, you should call the DOBI
at 1-609-292-5316 x50998, or call toll free at
1-888-393-1062 and ask that your appeal be
reviewed within 48 hours (two days ? weekends
and holidays count). You still must complete
the form.

Horizon NJ Health must accept the decision of
the IURO.

Fair Hearing
In addition to your right to Horizon NJ Health?s
appeal process, you may have the right to ask
the State to review Horizon NJ Health?s decision
about your service. This is known as a Fair
Hearing. This right applies to all NJ FamilyCare
A members as well as NJ FamilyCare ABP
members.

If you are not sure if you have a right to a Fair
Hearing, call Member Services toll free at
1-800-682-9090 (TTY 711).
If you are eligible and want to ask for a Fair
Hearing, as soon as you can, but no later than
120 calendar days from the date of Horizon
NJ Health?s decision letter on your Internal
Appeal, you must send a letter to the State at:

New Jersey Department of Human Services
Division of Medical Assistance and
Health Services
Fair Hearing Section
PO Box 712
Trenton, NJ 08625-0712

Let the State know in your letter:
1. Your name and Horizon NJ Health

ID number

2. Your doctor?s name

3. That you want a Fair Hearing

4. The reason you want a Fair Hearing

5. If the services are for urgent or emergency
treatment

6. Your telephone number

7. Include a copy of the Horizon NJ Health
denial letter

If you want to continue getting the benefits
in question during the Fair Hearing process,
you must request to do so in writing within
10 calendar days from the date of the notice
of adverse decision following the Internal
Appeal, or until the end of the prior approved
authorization, whichever is later. You must
follow this timeframe, even though you have

120 calendar days to request a Fair Hearing. If
you request continued benefits and your appeal
is denied, you may have to pay the cost of the
services.

At the hearing, someone outside of Horizon
NJ Health and the State will review your request
for services. This person is a judge from the
Office of Administrative Law (OAL), who will
listen to you and others who speak for or with
you at the hearing. You have the right to be at
the Fair Hearing or have a lawyer, friend or other
person go with or for you.

The OAL judge will give the State an opinion
on your request and the State will then decide
whether to accept or deny your request. The
State will give you its decision within 90 days,
unless your request is for urgent or emergency
treatment.

If you want to appeal the State?s decision,
you have the right to appeal to the Appellate
Division of Superior Court.