Grievance & Appeal Rights Under A Private Insurance Managed Care Plan
by
Herbert D. Hinkle, Esq. and Valerie A. Powers Smith, Esq.
Hinkle & Fingles, Attorneys at Law
2651 Main Street
Lawrenceville, New Jersey 08648
(609) 896-4200 or (215) 860-2100
This article provides an overview of the rights that are afforded to
an individual who has a managed care plan, which was either provided
by an employer or individually purchased.
1. Quality of Care. Complaints about quality of care issues are
properly addressed by filing a grievance with the insurance plan.
First, contact your Primary Care Physician (PCP). If your PCP is
unable to resolve the issue, you should call the managed care
organization’s (MCO) patient or member services department. The MCO
must respond to your grievance within 30 days. If you are still
dissatisfied, contact the New Jersey Departments of Health & Senior
Services (DOHSS) or Banking & Insurance (DOBI) to complain.
2. Health Benefit. If a covered health benefit has been denied,
reduced, or terminated, you may file an appeal. Private insurance
managed care plans provide a three-stage appeal process.
At each of the below mentioned stages of appeal, it has been my
experience that the more information provided, the more successful the
result.
Stage 1 – Informal Internal appeal. To initiate this level of appeal,
call the MCO and ask to speak to the medical director or physician who
made the decision regarding your case; state that you want to appeal
the decision; and that you want reconsideration of the decision
(provide as much information as possible as to why the decision should
be reconsidered). The MCO has 5 business days, or within 72 hours
(emergencies), to respond to your appeal. If the
MCO continues to deny or restrict coverage, it must inform you in
writing of their decision and how to proceed to a Stage 2 appeal.
Stage 2 – Formal Internal appeal. At this stage of appeal, your appeal
must be reviewed by physicians who are trained to practice in the same
specialty and would typically manage the case you are appealing. This
appeal must be promptly filed in writing and should include what you
want, along with supporting documentation. Once your appeal is
received, you are entitled to a decision within 20 business days, or
72 hours (emergencies). If the MCO needs more than 20 days to complete
their review, it must obtain permission from the State. If the Stage 2
appeal is denied, the MCO must give you written notice detailing the
reasons for denial and provide an explanation of your right to a Stage
3 appeal. If at any time the MCO fails to comply with the Stage 2
appeal requirements, you may proceed directly to Stage 3.
Stage 3 – External appeal. This appeal is filed with DOHSS, which
refers your appeal to an IURO (Independent Utilization Review
Organization). This appeal must be filed by you within 30 days of the
Stage 2 decision; and must include: (a) name and business address of
the MCO; (b) brief description of medical condition for which benefits
were denied, reduced, or terminated; (c) copies of Stages 1 and 2
written denial decisions from the MCOs; (d) written consent to obtain
any necessary medical records from the MCO or physician; (e)
application fee of $25.00; and (f) copy of the “summary of insurance
coverage” from your managed care member handbook. If the IURO accepts
your appeal, a decision will be issued within 30 days. The IURO’s
decision is binding on all parties.
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Herbert D.
Hinkle, his partner, Ira M. Fingles, and their colleagues, S. Paul
Prior and Valerie A. Powers Smith, maintain a statewide
law practice with offices in Lawrenceville, Marlton, and Florham Park,
New Jersey, and Yardley, Pennsylvania. They lecture and write frequently
on topics of law, aging, disability and estate planning and are available
to speak to groups in New Jersey and Pennsylvania
at no charge.
Comments and suggestions
for future articles should be mailed to: Hinkle & Fingles, 2651 Main Street, Suite A, Lawrenceville, New Jersey 08648-1012.
Copyright 2005
Herbert D. Hinkle. All rights reserved.
