2012 Healthfirst NJ Medical Part C - Organization Determinations, Appeals and Grievances
Organization Determinations
An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We and/or your provider make a coverage decision for you whenever you see your provider for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
If you wish to request a coverage decision for medical care, please contact Healthfirst NJ Medicare Plan:
Call:1-866-467-7178
TDD/TTY:1-800-852-7897
Monday through Friday, 8:30am-5:30pm
Fax:1-866-506-7060
Write: Healthfirst NJ Medicare Plan
Medical Management Department
P.O. Box 12103
Newark, NJ 07101-3403
When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
If your health requires it, ask us to give you a “fast decision.”
A fast decision means we will answer within 72 hours. However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing.
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days.
To get a fast decision, you must meet two requirements:
- You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
- You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision. If you ask for a fast decision on your own, without your provider’s support, our plan will decide whether your health requires that we give you a fast decision.
For more information on organization determinations, please review your Evidence of Coverage.
Who May Ask for a Coverage Determination?
You or someone you name to act for you (your appointed representative) may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-866-467-7178 (TTY/TDD 1-800-852-7897) if you need help filling out the form or want to learn more about appointing a representative.
Appointment of Representative form (English / Spanish)
Appeals
An appeal is a request to review the organization determination we made. For example, you can file an appeal if we did not pay for emergency or urgently needed care or if we discontinued a service or type of care you think you need. Appeals can be standard or fast. Standard appeals can take up to 30 days for a response. If you believe your health or ability to function could be hurt by waiting for a standard appeal, you may request a fast appeal. We will make a decision on a fast appeal within 72 hours.
If you wish to appeal a coverage decision for medical care, please contact Healthfirst NJ Medicare Plan:
| Standard Appeal Call:1-877-GO4-HFNJ (1-877-464-4365) TDD/TTY:1-800-852-7897 Monday through Sunday, 8am-8pm |
Fast (Expedited) Appeal Call:1-866-889-2527 TDD/TTY:1-800-852-7897 Monday through Friday, 8am-5pm |
Fax:1-866-505-7041
Write: Healthfirst NJ Medicare Plan
Appeals and Grievances Unit
P.O. Box 12102
Newark, NJ 07101-3402
When we make an appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. When we have completed the review, we give our decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
For more information on appeals, please review your Evidence of Coverage.
Grievances
A grievance is a complaint about any problem you have with Healthfirst NJ Medicare Plan or our providers. It does not pertain to payment or approval of Plan benefits which are called organization determinations. For example, you may complain about how long it takes to make an appointment or about the cleanliness of a provider’s office.
Call:1-877-GO4-HFNJ (1-877-464-4365)
TDD/TTY:1-800-852-7897
Monday through Sunday, 8am-8pm
Write: Healthfirst NJ Medicare Plan
Appeals and Grievances Unit
P.O. Box 12102
Newark, NJ 07101-3402
Who May Ask for a Grievance or an Appeal?
You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-877-464-4365 (TTY/TDD 1-800-852-7897) if you need help filling out the form or want to learn more about appointing a representative.
Appointment of Representative form (English / Spanish)
If you have a complaint, contact us promptly. You have 60 days after the date of the event or incident to make your complaint.
Usually, calling Member Services at the number listed above is the first step. If there is anything else you need to do, Member Services will let you know. If you do not wish to call or if you called but were not satisfied with the response, you can put your complaint in writing and mail it to us.
We will answer your complaint either in writing or by telephone (or both) no more than 30 days after the day we receive your letter. If you ask us to, or if we need more than 30 days to respond to your complaint, we may take another 14 days to answer.
Your complaint may be about the amount of time we take to make an organization determination (also called a coverage decision). For example, if we extend the timeframe for reaching a coverage decision, you can file a fast complaint. We will respond by phone within 24 hours of receiving your complaint and follow up with a written explanation within 3 days. If you are making a complaint because we denied your request for a fast response to a coverage decision, we will automatically give you a fast complaint.
For more information on grievances, please review your Evidence of Coverage.
Out-of-Network Medical Coverage
With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, when accessing additional benefits and services covered exclusively by Medicaid using your New Jersey issued Medicaid identification card (for our SNP members), and cases in which Healthfirst NJ Medicare Plan authorizes use of out-of-network providers.
See Chapter 3 of your Evidence of Coverage (Using the plan’s coverage for your medical services) for more information.
A Coordinated Care plan with a Medicare Advantage contract and a contract with the New Jersey Medicaid program.
Last Updated: 2/16/12
