The NJ Department of Banking & Insurance administers an external review program for prior authorization denials for procedures and prescriptions. Since 2014, physicians are required to post notice regarding the Independent Health Care Appeals Program (IHCAP) in their office.
IHCAP is available to patients and physicians, with patient consent. DOBI utilizes Independent Utilization Review Organizations (IUROs) to evaluate these cases. There is a $25 filing fee that is refunded if the payer’s decision is reversed (the fee may be waived for financial hardship). Generally, stage 1 and 2 internal appeals must be completed before claims may be sent to the IURO. However, if the payer fails to meet the requisite appeal timeframes for the medical exigencies of the case or an application for expedited external and internal review were filed at the same time, the claim can go straight to the IURO. Read more about the program on DOBI’s website. Additional resources are available at www.msnj.org/priorauthorization.