1
INTERNAL APPEAL
You, your authorized representative, or your
provider acting with your written consent have
the right to file an Internal appeal if you disagree
with a medical decision Horizon NJ Health has
made. If you decide to appeal, you must ask for
an Internal appeal no later than 60 days after you
receive our denial decision letter.

How do I file an Internal Appeal?

You, your authorized representative, or your
provider acting with your written consent has the
right to request an appeal by phone or in writing.
All verbal appeal requests must be followed up
with a written, signed letter, except in the case
of a medically urgent appeal.
An appeal can be requested by phone by calling
1-800-682-9094, x89606, select prompt 2
(TTY/TDD 711).
You can also fax an appeal to the Appeals
Department at 1-609-583-3028 or you can
mail a written request to the following address:

Horizon Medical Appeals
PO Box 10194
Newark, NJ 07101

When filing an appeal, please include your
name, Horizon NJ Health Member ID#, and
your treating provider?s name. You must state
that you want to appeal our decision and
give the reason why you want to appeal. It
is really important to include any supporting
documentation, comments or other information
you think we need to know when you submit
your appeal. Members and providers can
submit written comments, documents or other
information relevant to the appeal.

You or your provider may request and get a copy
of the regulation, benefit provision, guideline,
protocol or other similar criterion which includes
access to and copies of all documents used in
this decision, free of charge upon request.

NOTE: If you or your treating provider believe
that waiting for our Internal appeal decision
could harm your health; or if the services are
for urgent or emergent treatment, you or your
treating provider may request an expedited
appeal by calling the Horizon NJ Health Appeals
Coordinator at 1-800-682-9094, x89606, select
prompt 2 (TTY/TDD 711). Horizon NJ Health
will notify you of our expedited appeal decision
verbally and in writing within 72 hours of receipt
of your expedited appeal request (includes
weekends and holidays).

Appeals Guide and Your Rights
This guide is designed to provide information on what you can do if you want to
challenge (appeal) a medical decision that you do not agree with. We want to make
sure you understand your rights and assist you with understanding the different appeal
options you may have.

Let?s start with an explanation of the Internal and External appeal processes.
? The first step for an appeal can be a request to Horizon NJ Health. This is an

Internal appeal.
? The next step is an External appeal and can happen after you complete the first

step or Internal appeal.
? Your External appeal can be a Fair Hearing and/or an Independent Utilization

Review Organization appeal. These are not done by Horizon NJ Health.

horizonNJhealth.com

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2 horizonNJhealth.com

What happens during the Internal appeal
process?

All Internal appeals are reviewed by a licensed
physician reviewer or consultant (providers) who
practices the same or a similar type of medicine
as your provider. This physician reviewer or
consultant will not have participated in any
decisions related to your current requested
services. Horizon NJ Health will notify you of
the Internal appeal decision within 30 calendar
days (includes weekends and holidays) of your
request. When we send you the Internal appeal
decision, we will include an explanation of our
decision and information on what your options
are if you disagree.

The services you are already receiving will
automatically continue during the appeal
process provided you ask for the appeal on or
before the last day of the previously approved
authorization or within 10 calendar days of the
denial decision, whichever is later.

What if I am not satisfied with the decision
regarding my Internal appeal?

If you do not agree with the decision Horizon
NJ Health made during the Internal appeal, you,
your authorized representative, or your provider
have the right to request an External appeal with
the Independent Utilization Review Organization
(IURO) or a Fair Hearing (for some members).
You may request an IURO and Fair Hearing at
the same time. You must complete the Internal
appeal prior to requesting the Fair Hearing
appeal.

EXTERNAL APPEAL
You, your authorized representative, or your
provider acting with your written consent have
the right to file for an External appeal if you
disagree with the results of the Internal appeal.
An External appeal with the IURO must be filed
with the Independent Health Care Appeals
Program (IHCAP) operated by the New Jersey
Department of Banking and Insurance (DOBI).

We will include the External Appeal application
in our Internal appeal decision letter. The form
includes information about the IHCAP, mailing
instructions and contact information.If your
provider wishes to file an External appeal on your
behalf, he or she will also need to complete and
submit to DOBI a ?Consent to Representation in
Appeal of UM Determination and Authorization
of Release of Medical Records in UM Appeals and
Independent Arbitration of Claims? form.

The consent form is available on the
NJ Department of Banking and Insurance website
www.state.nj.us/dobi/umappeal.htm.

You can contact DOBI directly with questions
about the IURO appeal process by calling
1-888-393-1062, x50998.
Appeals must be filed with IHCAP within
60 days of receipt of the Horizon NJ Health
Internal Appeal decision letter.
You must send your External IURO appeal to the
following address:

New Jersey Department of
Banking and Insurance
Office of Managed Care ?
Attn: IHCAP
PO Box 329
Trenton, NJ 08625-0329

What if I want my services to continue while
I am waiting for the External IURO appeal
decision?

The service you are already receiving will
automatically continue during the External appeal
process provided you ask for the appeal on or
before the last day of the previously approved
authorization or within 10 calendar days of the
Internal appeal decision letter, whichever is later.

Please note that the External IURO appeal process
is not available for the following services:

? Adult Family Care
? Assisted Living Program
? Assisted Living Services ? when the denial

is not based on Medical Necessity
? Caregiver/participant training
? Chore services
? Community Transition Services



3Member Services: 1-800-682-9090

? Home Based Supportive Care
? Home Delivered Meals
? Personal Care Assistant (PCA) services
? Respite (Daily and Hourly)
? Social Day Care
? Structured Day Program -- when the denial

is not based on Medical Necessity
? Supported Day Services -- when the denial

is not based on the diagnosis of Traumatic
Brain Injury (TBI)

To appeal the above services after an Internal
appeal, you may file for a Fair Hearing.

FAIR HEARING
NJ FamilyCare A and NJ FamilyCare ABP members
may ask the NJ Department of Human Services for
a Fair Hearing if they disagree with the Internal
appeal decision or the appeal decision by the
IURO. The Internal appeal process must be
completed first before a Fair Hearing can be
requested. A Fair Hearing takes place in a court
room. A hearing is held in front of an
Administrative Law Judge.
How do I file for a Fair Hearing?

Do not send a Fair Hearing request to Horizon
NJ Health. We are not able to process them for
you. You must send all Fair Hearing requests to
the Department of Human Services at the
following address:

New Jersey Department of Human Services
Division of Medical Assistance and
Health Services
Fair Hearing Section
PO Box 712
Trenton, NJ 08625-0712

It is really important that you send your written
request for a Fair Hearing to the Department of
Human Services no later than 120 calendar days
from the date of the Internal appeal denial
letter. At this court hearing, you have the right
to represent yourself, or choose to be
represented by an attorney, friend or other
spokesperson.

What should I include when I write to ask
for a Fair Hearing?

Fair Hearing requests must be in writing and you
must include the following information:

? Your printed name
? The date
? Your telephone number
? The reason(s) why you want a Fair

hearing
? If you would like an interpreter to be present

at the Fair Hearing, please let Horizon NJ
Health know. We will provide an interpreter
in the language you need. Call
1-800-682-9090 (TTY/TDD 711). You may
also bring a relative or friend to interpret
for you.

What if I want my services to continue while
I am waiting for the Fair hearing?

If you would like the service to continue during
the Fair Hearing process, you must ask for that
in writing when you request a Fair Hearing and
you must ask for the appeal on or before the last
day of the previously approved authorization or
within 10 calendar days of the last appeal
decision letter, whichever is later.

Please note that if we continue to provide the
services and the judge decides that Horizon NJ
Health?s denial decision was correct, you may
have to pay for the costs of the services.

NEED HELP? THIS IS REALLY IMPORTANT

You have the right to have a representative act
on your behalf at all levels of appeal. If you have
any questions, comments or concerns about
your appeal or the appeal process; or you need
assistance with filing any type of appeal or a
Fair Hearing Request, please call
1-800-682-9094, x89606, prompt 2
(TTY/TDD 711).



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RIGHT TO REPRESENTATION

You have the right to represent yourself,
have someone else represent you, or have
legal representation. If you would like legal
representation and are not able to pay for this,
you can contact one of the following:

? Legal Services of New Jersey at
LSNJLawHotline.org or call Legal Services
of New Jersey at 1-888-576-5529;

? Disability Rights New Jersey (DRNJ)
at advocate@drnj.org or call DRNJ at
1-800-922-7233 (TTY/TDD 711) for free
legal and advocacy services for people
with disabilities; or

? Community Health Law Project (CHLP)
at chlpinfo@chlp.org or call CHLP at
1-973-275-1175 to be directed to the
appropriate office serving your county.
A list of CHLP offices can also be found
at chlp.org.

28137 (W05/17)
Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise,
an independent licensee of the Blue Cross and Blue Shield Association.
? 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

Para recibir una copia de esta carta en
espa?ol, llame gratis al 1-800-682-9094
Horizon NJ Health, x89606.