How to appeal a health insurance denial in New Jersey
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. New Jersey lets you ask an independent reviewer to decide, through New Jersey Department of Banking and Insurance. The deadline to ask: within four months of receiving the decision on the internal appeal (60 days for Medicaid/NJ FamilyCare members).
Does this apply to you? State external review covers plans regulated by New Jersey: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in New Jersey
Within four months of receiving the decision on the internal appeal (60 days for Medicaid/NJ FamilyCare members)
The reviewer decides expedited appeals within 48 hours of submission. You can file an expedited external appeal at the same time as an expedited internal appeal. Services you have already received cannot be expedited.
Free (DOBI waived the $25 filing fee in its regulation, and the carrier pays for the review)
State-regulated plans (insurance bought in New Jersey or through an employer that buys insurance). Self-funded employer plans use the federal process.
Run by DOBI's Independent Health Care Appeals Program (IHCAP). Since 1/1/2022 you file directly with the state's contractor, Maximus (online, fax 585-425-5296, or mail; questions 888-866-6205). DOBI's IHCAP line is 888-393-1062. Group plans usually require both internal stages (Stage 1 and Stage 2) first. The State Health Benefits Program, Medicare and self-funded plans are excluded. The statute (N.J.S.A. 26:2S-11) still says 60 days, but DOBI's regulation and pages give at least four months.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in New Jersey?
Within four months of receiving the decision on the internal appeal (60 days for Medicaid/NJ FamilyCare members)
Can I get a fast external review in New Jersey?
The reviewer decides expedited appeals within 48 hours of submission. You can file an expedited external appeal at the same time as an expedited internal appeal. Services you have already received cannot be expedited.
Does external review cost anything in New Jersey?
Free (DOBI waived the $25 filing fee in its regulation, and the carrier pays for the review)
Do New Jersey’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- NJDOBI: How to File a Utilization Management Appeal
A request for an external appeal must typically be filed within four months of receipt of the decision on the internal appeal.
- NJDOBI: Independent Health Care Appeals Program
Expedited reviews are decided by the IURO within 48 hours from when the appeal request was submitted.
- DOBI Bulletin No. 21-13
The applicant fee waiver remains in effect.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.