Appeals of Utilization Management/Medical Management Determinations

An adverse benefit determination involving a medical necessity decision is a decision to deny or limit an admission, service, procedure or extension of stay based on Horizon BCBSNJ’s medical necessity criteria. Adverse benefit determinations may usually be appealed up to three times. Individual consumer plans and some ASO/self-insured plans only allow one level of appeal.*

Please refer to the appropriate Horizon BCBSNJ manual for additional information on the Utilization/Medical Management Appeal Process.

• Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 1: Use this form to notify of the intent to file a Stage 1 appeal to an adverse Utilization Management (UM) decision.
• Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 2: Use this form to notify of the intent to file a Stage 2 appeal to an adverse Utilization Management (UM) decision.
• Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 3: To provide notice of the intent to file a Stage 3 appeal to an adverse utilization management (UM) decision.
• Appeal to Independent Health Care Appeals Program (IHCAP): If a member’s medical appropriateness request is denied by the Horizon BCBSNJ appeals process, the member may use this form to appeal that decision to the Independent Health Care Appeals Program (IHCAP) run by the New Jersey Department of Banking and Insurance (DOBI).

* 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.