New Jersey health insurance appeal rights

Denied in New Jersey? After your internal appeals, you can request a free, binding external review through the state’s Independent Health Care Appeals Program (IHCAP). Here’s how it works — and why the deadline is four months.

Get your free diagnosis

How appeals work in New Jersey

New Jersey uses a multi-stage path after a denial. You first appeal to your carrier internally, then — if the carrier still says no — you can request an external review through the Independent Health Care Appeals Program (IHCAP), run by the New Jersey Department of Banking and Insurance under the Health Care Quality Act. An Independent Utilization Review Organization (IURO) — currently Maximus Federal Services — reviews the case, and its decision is binding on the carrier.

External review generally applies when a carrier denies care as not medically necessary, experimental or investigational, or cosmetic. (Self-funded employer plans, Medicare, the Federal Employees program, and the State Health Benefits Program aren’t eligible — they have their own systems, and your denial letter will say which applies.)

Step 1 — your internal appeal(s)

Start with your carrier’s internal appeal. At Stage 1, the carrier has the case reviewed by a provider not involved in the original decision (a determination is generally due within 10 business days — 72 hours for urgent care). If you’re in a group plan and still disagree, you can go to Stage 2, a panel review (generally due within 20 business days). Individual-plan and NJ FamilyCare members skip Stage 2. Federal rules also give you at least 180 days to file each internal appeal — check your own notice.

Step 2 — request an external appeal (IHCAP)

Once you’ve completed the carrier’s internal appeals, file your external appeal with Maximus, in writing, with your carrier’s written decision(s), evidence of coverage, and the medical records you want reviewed. The review is free — the carrier pays for it. A standard external appeal is decided within 45 calendar days; an expedited appeal for urgent cases is decided within 48 hours. If the IURO reverses the denial, the carrier must provide coverage for the services found to be medically necessary.

Where to file and get help

• File an external appeal — online with Maximus (NJ IHCAP); you can also request a paper form to mail or fax.
• Maximus (application questions) — 888-866-6205 or Stateappealseast@maximus.com.
• NJ DOBI (program questions) — ihcap@dobi.nj.gov, 1-888-393-1062 or 609-777-9470.

Putting it together

Read the denial, complete your carrier’s internal appeals, then request the free IHCAP external review — and mind the four-month deadline. Our step-by-step guide covers each stage, external review explains independent review generally, and our appeal-deadline guide helps you track your dates. In another state? See Pennsylvania or New York appeal rights.