External Appeals. Participating Provider acting on behalf of a Member with the Member’s consent, may appeal a final internal Adverse Benefit Determination, except where the final internal Adverse Benefit Determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to Medical Necessity, through the Independent Health Care Appeals Program to an independent utilization review organization (“IURO”). Any stage 3 external appeal through the Independent Health Care Appeals Program must be filed within four (4) months of receipt of the final internal Adverse Benefit Determination. The external appeal request shall be filed on the forms provided in accordance with N.J.A.C. 11:24A-3.5(k)4 and mailed to the Department of Banking and Insurance, Consumer Protection Services, Office of Managed Care, X.X. Xxx 000, Xxxxxxx, Xxx Xxxxxx 00000-0000.
Appears in 4 contracts
Samples: Qualcare Provider Network, Qualcare Provider Network, Qualcare Provider Network
