5. MARCO TEÓRICO
5.1. CUBIERTA VERDE Y JARDIN VERTICAL
Horizon NJ Health has developed and implemented policies and procedures to receive and adjudicate appeals from participating physicians, vendors and facilities of health care services related to adverse dental utilization management determination(s). Any provider can request a reconsideration of a determination not to certify an admission, a continued hospitalization or a level of care determination. Medical appeals are appeals of
determinations regarding dental utilization management appropriateness filed directly by the physician or health care professional not on behalf of the member.
Please note that a dentist, physician or health care professional has the option of whether to file a Provider Utilization Management Appeal or a Member Utilization Management Appeal (on behalf of the member).
Hospitals may obtain consent from the covered person prior to receiving hospital services.
This consent is valid for all stages of internal and external appeals. Patients may revoke consent at any time. Dentists, physicians and/or other health care professionals must provide the covered person notice of an appeal whenever an appeal is initiated, and again each time the appeal is continued to the next stage, including any appeal to an IURO. Information on filing a Member Dental Medical Appeal is set forth in Section “Utilization Management Member Appeal Process.”
A dentist, physician or health care professional may not initiate both utilization management appeals processes with respect to the same appeal.
Utilization Management Dental Appeals
The procedure to process an appeal is as follows: 1. A dentist, physician, vendor and/or facility maysubmit a formal written request for further review of a Horizon NJ Health utilization management decision. The appeal must be submitted within 90 days of receiving a denial letter for an inpatient service or an outpatient service or within 60 days from the date of the complaint/grievance notification. Health care professionals must submit all appeal requests in writing except when the request is for an expedited resolution. All written appeal requests must be submitted to the following address:
Horizon NJ Health Appeals Unit P.O. Box 295
Milwaukee, WI 53201
2. All appeals (regardless of level or type) must include the following information:
• Name, address and phone number of the
physician(s), vendor or facility making the appeal; • Member identification number;
• Date(s) of service;
• Name(s) of physician, vendor or facility whereby services were rendered;
• Specific details regarding the actions in question; • The nature and reasoning for the appeal;
• The desired outcome;
• Supporting documentation, i.e. dental record.
Continuation of Benefits
Services are covered while an appeal is pending. If the member requests a Medicaid Fair Hearing and wishes to request continuation of benefits, they must do so in writing within 10 days of the date of the denial. If the appeal is denied, the member may be required to pay for the cost of these services.
Stage One Appeal
A health care professional who is dissatisfied with any utilization management determination will have the opportunity to speak to and appeal that determination with the Dental Director or physician designee who rendered the determination.
Verbal and written notification of urgent or emergent appeals determinations will be completed as soon as possible and will not exceed 72 hours after the initiation of the appeal request.
Stage One utilization management appeal determinations, including written notifications, will be completed within 20 business days, and will not exceed 30 calendar days of the initiation of the Stage One appeal request.
If the appeal is not resolved to satisfaction, we will provide a written explanation as how to proceed to a Stage Two appeal. Stage Two appeals must be filed within 60 days from the receipt of the action from the Stage One appeal. All adverse determination letters will document the clinical rationale for the decision including a statement that the clinical rationale used in making the appeal decision will be provided in writing upon request.
Stage Two Appeal
Upon receipt of all required information, the case will be presented to the
Horizon NJ Health Level TwoAppeals Committee, which is a panel of physicians and/or other health care
professionals not involved in the utilization management determination. The Appeals Committee will have available a consulting practitioner who is trained or practices in the same specialty as would typically manage the case being appealed. The Committee will review the case and make a determination.
Verbal and written notification of urgent or emergent appeals determinations will be completed as soon as possible and will not exceed 72 hours after the initiation of the appeal request.
Stage Two utilization management appeal determinations, including written notification, will be completed within 20 business days and will not exceed 30 calendar days of the initiation of the Stage Two appeals. All adverse determination letters will document the clinical rationale for the decision and include a declaration that the clinical rationale used in making the appeal decision will be provided in writing upon request.
Horizon NJ Health Appeals 210 Silvia St. West Trenton, NJ 08628 Phone: 1- 800-682-9094 Ext 89609 Option #2
Claim Appeals Process
This section describes procedures through which participating and nonparticipating health care
professionals have a right to a written appeal of disputes relating to payment of claims as defined below.
As always, Horizon NJ Health procedures are intended to provide our Participating Dentists with a prompt, fair and full investigation and resolution of their claims.
The procedure includes a Stage Two, binding and nonappealable external Alternative Dispute Resolution