New Jersey

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • 1. Appeal the decision;
  • 2. Request an external review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. The appeal process differs based on whether you have an employer-sponsored group plan or any other type of plan.

To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited internal appeal, if applicable. You can request an expedited internal appeal if your case involves urgent or emergency care, an admission, availability of care, continuation of a stay, and situations in which you have received emergency services and have not yet been discharged from the facility.[2] If you believe you qualify or an expedited internal appeal, you should contact your insurer and ask for instruction on how to request one.
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

If you have an employer-sponsored group plan, you will need to complete two stages of internal appeals.[3] During the first stage, you or your provider should call your health insurer’s medical director or the physician responsible for denying your claim.[4] You may also have to complete all the steps listed above in section I. Your insurer can provide you with clarification.

During the stage-two appeal, you or your provider can appeal the denial to a panel of physicians or other health care professionals selected by your health insurer.[5]  The providers on the panel must not have been involved in the original denial of your claim and must have access to practitioners who are trained in or who specialize in the condition for which you are seeking treatment.[6] You should contact your insurer for instructions on how to request a stage-two appeal.

The first stage of an internal appeal should take no longer than 10 days to complete, while the second stage should be completed in no more than 20 business days.[7]

For expedited internal appeals, the first stage should be completed within 72 hours, and the second stage should also be completed within 72 hours.[8]

During an external review, an independent third party reviews your insurer’s decision.[9] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under New Jersey law, you are entitled to request an external review if:

  • Your insurer denies your internal appeal because it determined that the requested treatment or services were medically unnecessary, experimental, or investigational;
  • Your insurer has not complied with the deadlines for deciding your internal appeal;
  • Your insurer has waived the internal appeals process; or
  • Your situation is urgent and you requested an expedited internal appeal and an expedited external review at the same time.[10]

You can request an expedited external review if:

  • You seek urgent or emergency care, an admission, availability of care, or continuation of a stay;
  • You have received emergency services and have not yet been discharged; or
  • Waiting 10 to 20 days could seriously jeopardize your life, health, or ability to regain function.[11]

You should submit your request for an external review to the New Jersey Department of Banking and Insurance (“Department”) within four months from when your insurer sent you the most recent decision.[12]

Information. You can find a copy of the external review request form here. You should include the following information in your request:

  • The name, address, telephone number, email address, and date of birth of the insured individual;
  • The name of the insurance company;
  • The identification number and policy number;
  • The name, address, telephone number, and email address of the person filing the request and his or her relationship to the patient;
  • A description of the reason for the appeal; and
  • If you are requesting an expedited external review, a statement that you are requesting expedited review and the reasons why you believe expedited treatment is needed.[13]

Supporting documents. You should include copies of the following supporting documents with your request:

  • A signed medical records release form;
  • All information submitted to the health insurer;
  • Any additional or new information you would like the external review organization to consider;
  • A copy of the initial denial letter from your health insurer; and
  • Copies of the insurer’s decisions on the internal appeals.[14]

Do not send copies of your medical records with the request. The Department will give you instructions on how to submit copies of your medical records after the external review organization accepts your request.

Submitting a standard external review. You can email your request to [email protected], or mail it to:

NJ Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
P.O. Box 329
Trenton, NJ 08625-0329[15]

(If using courier service: 20 West State St., 9th Floor)

Submitting an expedited review. For expedited requests, you can fax the request and supporting documents to (609) 633-0807.

Filing Fee. There is a $25 processing fee for applications accepted by the external review organization. The fee may be waived if you can show financial hardship.

The external review process should take no more than 45 days after the external review organization has received your request. If you requested an expedited external review, the process should take no more than 48 hours.[16]

If you are a New Jersey resident and your insurer still denies your claim after the external review process, you can file a complaint with the Department.

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different than the Complainant;
  • The name and address of the insurance company;
  • The policy number, claim number, and date of loss/claim;
  • The nature of the complaint;
  • The details of the complaint; and
  • The action requested.[17]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[18]

How to submit. The complaint may be submitted online here, faxed to (609) 454-8468, or mailed to the following address:

New Jersey Department of Banking and Insurance
Consumer Inquiry and Response Center
P.O. Box 471
Trenton, NJ 08625-0471[19]

Your complaint will be assigned to an investigator. The investigator will review the complaint and contact your health insurer for a response. The insurer has 14 days to respond. Once the review is complete, the investigator will notify you of any action taken.[20] The Department can force the insurer to cover the claim, or issue a citation or fine. If a death has occurred because of action or inaction by the health insurer, the Department can bring criminal charges against the insurance company. Complaints are usually resolved within 60 days.

You can contact the New Jersey Department of Banking and Insurance at (609) 292-7272 or through the Consumer Hotline at (800) 446-7467. The Department is open from 9:00 a.m. to 4:00 p.m., Monday through Friday.