Appeals of Non-Utilization Management Determinations

Member Appeals – Requesting an Appeal*

Following the receipt of the complaint determination, in appropriate instances, the member/covered person, or a physician or other health care professional on behalf of, and with the consent of the member or covered person, may request an appeal either orally, in person or by phone or in writing as instructed by Horizon Blue Cross Blue Shield of New Jersey in its complaint determination.

Horizon BCBSNJ’s written complaint determinations will detail the member’s appeal rights. Members are directed to send their appeal requests, whether by phone or in writing, to the appeals unit at the address and phone number supplied.

An appeals coordinator investigates the case and collects the information necessary to forward the case to the appeals committee.

Within five calendar days of receiving the appeal request, the appeals coordinator sends the member/covered person a letter acknowledging the request for appeal, describing the appeals committee process and advising of the actual hearing date.

• Appeal a Claims Determination: Use this form to appeal a claims determination by Horizon BCBSNJ (or its contractors) on previously-submitted claims, or to appeal an apparent lack of action toward resolving a previously-submitted claim.
• Appeal a BlueCard Claims Determination: Use this form to appeal or dispute a rejected BlueCard® claim.
• Waiver of Liability Statement: Nonparticipating providers may use this form as part of an appeal of a rejected claim for services provided to a Medicare Advantage member.

* Members/covered persons enrolled in some plans do not have the appeal rights described here. For example, our Medicare Advantage members follow a different appeal policy, and members/covered persons of certain plans, such as individual consumer, ASO accounts and self-insured accounts, may not have the appeal rights described here.

Member Appeals – Resolving the Appeal

Cases are scheduled within five days of receiving the request for an appeal related to a pre-service determination and within 10 days for an appeal related to a post-service claim. Appeals that involve requests for urgent or emergent care may be expedited.

The member/covered person is given the option of attending the hearing in person or via phone conference. The appeals coordinator makes the appropriate arrangements.

Members/covered persons, or physicians and other health care professionals on behalf of, and with the consent of, members or covered persons, who participate in the hearing are notified of the committee’s decision verbally, on the day of the hearing, whenever possible. Written confirmation of the decision is sent to the member/or covered person and/or the physician or health care professional who pursued the appeal on their behalf, within two business days of the decision. Members/covered persons who choose not to appear are notified of the committee’s decision in writing within two business days of the decision.

Appeals are decided within 15 days of receipt for pre-service determinations and 30 days of receipt for post-service claims.

Letters of decision advise members what other remedies may be available to them if they remain dissatisfied with the resolution reached through the internal complaint system.