You can file a complaint, grievance or appeal, or your PCP or another representative can do it for you, with your permission. You, your PCP, or your representative may also call the state Medicaid hotline at 800-356-1561 for help. 

Complaints

You may occasionally encounter problems with your HMO about issues like difficulty scheduling appointments, physical or communication barriers, use of the HMO’s 24-hour phone service or member services, a disagreement with a care provider, or an inappropriate bill for a covered service.

Try to resolve the problem where and when it originates.  Most problems can be resolved by talking directly to your PCP, care manager, or other provider about them.  You might also start with your PCP or care manager if you have any concerns about other processes or people in the HMO; your concerns may be simple to address.  You can also call the Medicaid hotline or the Managed Care Consumer Assistance Program (MHCCAP) helpline for advice on how to proceed.

If this doesn’t resolve the problem to your satisfaction, call your HMO member services and file a complaint.  Be specific about why you are dissatisfied.  If the HMO can’t resolve the problem within 24 hours, you may register a grievance with the HMO by phone or letter within 60 days of the incident that caused the problem (it’s good to file it in writing because then the state Medicaid office automatically gets a copy).

If you are not satisfied with the HMO’s solution to your complaint, you can also call the state Medicaid Hotline at 1-800-356-1561 or the MHCCAP Helpline at 1-888-838-3180.

If your complaint is about urgent care, you or your PCP should request an urgent grievance decision. The HMO must then resolve your grievance within 48 hours.

You have the right to make complaints, grievances, and appeals in your primary language and have them handled in that language.

APPEALS

Your HMO must notify you in writing at least 10 days before it denies or limits covered services to your child.  If this happens to you and you disagree with the decision, you may file an appeal of the denial with your HMO.  An appeal can sometimes be resolved easily, but the process can become very complicated, so you will probably want advice.  Your PCP or care manager may be able help you, or consult the Family Voices Resource List.  Again, read your member handbook carefully; you may find all the answers you need right there! 

At the end of each stage of the process, if your HMO continues its denial, by law it must inform you in writing of its reasons for denial, and tell you how to proceed to the next stage.  Always follow the instructions provided.  The HMO also must respond to you at every level within a specified time (see your member handbook or call the Medicaid hotline).  The HMO must also inform you that you have the right to request a Medicaid Fair Hearing at any time during the appeals process. 

Internal Appeals:  You can appeal at two levels within the HMO – the first with the medical director or the physician who denied coverage; the second with physicians who were not involved in the first appeal and who might typically care for children with needs similar to your child’s.

External Appeals:  If the HMO’s responses to your appeals are unsatisfactory to you, apply to the NJ Department of Health and Senior Services to refer your appeal to an Independent Utilization Review Organization (IURO) (cost $2).  The IURO reviews your appeal, and if it accepts your case, issues a decision to you and/or your PCP, and to your HMO.  If the IURO decides in your favor, the HMO must promptly provide coverage.

During appeals to your HMO and the state Medicaid office, you may also request a Medicaid Fair Hearing.

Ask for an immediate review in any urgent situation.  Write “Emergency Decision Required” on all envelopes and letters, and tell anyone you speak to that you require an emergency decision.

Of course, if your child requires emergency medical care, call 911 or go to the nearest emergency room!

Medicaid Fair Hearing

At any time in the appeals process (but within 90 days of the denial) you can file for a fair hearing with the state Department of Human Services (call the Medicaid hotline).  When your HMO denies, reduces, or delays a service, it must also explain in writing your right to a fair hearing and how to obtain one.

Helpful Pointers 

• Know the definition of medical necessity.  It is commonly the basis of service denials or limitations.

• Know your responsibilities as well as your rights.  You are accountable for upholding them.

• Keep a record  of every personal or phone contact with dates, names, phone #s, outcomes, when to expect a call-back, etc.

• Keep copies of all written contacts, including letters you send or receive from your HMO (your HMO will also be documenting every contact you have with it)

• Mail all correspondence by certified mail with return receipt requested

• Bring legal representation to any fair hearing proceeding

• Read and understand your member handbook; ask questions if you don’t understand

• Don’t hesitate to ask for advice about complaint, grievance, or appeal processes.  They’re complicated!

• Every year your HMO will provide you with the most up-to-date information about the grievance process – be sure to stay current on the information