ࡱ> 7 Vbjbj(( FJdJdIJJ  84rN|(H%,Q$!v$Qi@ii,ipi2C `B0rj%j%j%iiiiiiiiiiriiiij%iiiiiiiiiJ j: New Jersey Department of Banking and Insurance CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS IN UM APPEALS AND INDEPENDENT ARBITRATION OF CLAIMS  APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS You have the right to ask your insurer, HMO or other company providing your health benefits (carrier) to change its utilization management (UM) decision if the carrier determines that a service or treatment covered under your health benefits plan is or was not medically necessary. This is called a UM appeal. You also have the right to allow a doctor, hospital or other health care provider to make a UM appeal for you. There are three appeal stages if you are covered under a health benefits plan issued in New Jersey. Stage 1: the carrier reviews your case using a different health care professional from the one who first reviewed your case. Stage 2: the carrier reviews your case using a panel that includes medical professionals trained in cases like yours. Stage 3: your case will be reviewed through the Independent Health Care Appeals Program of the New Jersey Department of Banking and Insurance (DOBI) using an Independent Utilization Review Organization (IURO) that contracts with medical professionals whose practices include cases like yours. The health care provider is required to attempt to send you a letter telling you it intends to file an appeal before filing at each stage. At Stage 3, the health care provider will share your personal and medical information with DOBI, the IURO, and the IUROs contracted medical professionals. Everyone is required by law to keep your information confidential. DOBI must report data about IURO decisions, but no personal information is ever included in these reports. You have the right to cancel (revoke) your consent at any time. Your financial obligation, IF ANY, does not change because you choose to give consent to representation, or later revoke your consent. Your consent to representation and release of information for appeal of a UM determination will end 24 months after the date you sign the consent. INDEPENDENT ARBITRATION OF CLAIMS Your health care provider has the right to take certain claims to an independent claims arbitration process through the DOBI. To arbitrate the claim(s), the health care provider may share some of your personal and medical information with the DOBI, the arbitration organization, and the arbitration professional(s). Everyone is required to keep your information confidential. The DOBI reports data about the arbitration outcomes, but no personal information will be in the reports. Your consent to the release of information for the arbitration process will end 24 months after the date you sign the consent. CONSENT TO REPRESENTATION IN UM APPEALS AND AUTHORIZATION TO RELEASE OF INFORMATION IN UM APPEALS AND ARBITRATION OF CLAIMS I, PRINT NAME , by marking " (or x ) and signing below, agree to:  FORMCHECKBOX  representation by  FORMTEXT       in an appeal of an adverse UM determination as allowed by N.J.S.A. 26:2S-11, and release of personal health information to DOBI, its contractors for the Independent Health Care Appeals Program, and independent contractors reviewing the appeal. My consent to representation and authorization of release of information expires in 24 months, but I may revoke both sooner.  FORMCHECKBOX  release of personal health information to DOBI, its contractors for the Independent Claims Arbitration Program or the Chapter 32 Independent Arbitration System, and any independent contractors that may be required to perform the arbitration process. My authorization of release of information for purposes of claims arbitration will expire in 24 months. Signature: ___________________________________________ Ins. ID#:______________ Date: ___________ Relationship to Patient:  FORMCHECKBOX  I am the Patient  FORMCHECKBOX  I am the Personal Representative (provide contact information on back) New Jersey Department of Banking and Insurance NOTICE OF REVOCATION OF CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND OF AUTHORIZATION TO RELEASE OF MEDICAL RECORDS You may, at any time, revoke the consent you gave allowing a health care provider to represent you in an appeal of a UM determination and allowing the release of your medical records to the DOBI, the IURO and medical professionals that contract with the IURO. You may use this form to revoke your consent, or you may submit some other written evidence of your intent to revoke consent, if you prefer. Either way, if you have not yet received a Stage 2 UM determination from the carrier, send the written and signed revocation to the carrier at the address indicated in the carriers written notice to you regarding the carriers initial UM determination. If you have received a Stage 2 UM determination, then your revocation should be sent to: New Jersey Department of Banking and Insurance Consumer Protection Services Office of Managed Care Attn: IHCAP P.O. Box 329 Trenton, Sexy 08625-0329 OR for courier service to: 20 West State Street OR by fax to: (609) 633-0807 You may also want to send a copy of your notice of revocation to the health care provider. ONLY COMPLETE AND SEND THIS IN WHEN AND IF YOU WISH TO REVOKE YOUR CONSENT! REVOCATION OF CONSENT TO REPRESENTATION AND RELEASE OF MEDICAL RECORDS IN UM DETERMINATION APPEALS  FORMCHECKBOX  I hereby revoke my consent to representation by  FORMTEXT       and my authorization to the release of medical information in an appeal of an adverse UM determination. I understand that by revoking consent, the UM appeal may not be pursued further by my health care provider. I understand that this revocation may occur after my personal and medical information has already been shared with the DOBI, the IUROs and medical professionals with whom the IUROs contract, but that no further distribution of records in this matter will occur based on my authorization, and that all of my medical and personal information is required to be maintained as confidential by all parties. Signature: Ins. 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9~~~~~~}}}r}pf8r $jA4`9G #M67=unpr~~}~~~~~~}qppfVU! 0A$4?=zWX{[|==uospr}}~~~}qqrqqpobdK#sUUhijC?+5kQ#lMmf87==`nnoopqrqqpqqstntt``u`cZvOWNwxUy.&UA#$ (*>7DVWXYZ[\]^_=^_`ab`caa6defgPW:_TUU&&A #B-C,(?DEFGHIJKLMMMNNOKPI QFRST*-. 0U123,*)45678899::::::;<887=>?*&-@0"!#$%"&"'())*+)*)*),,-./# 0   !   &TNPP'8K)@Georgia---  2 Y2)K8  'K@--- P2 W.@KNew Jersey Department of Banking and Insurance       2 W@K  @"Gill Sans MT--- Y2 i4@KCONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION             /2 z@KMANAGEMENT DETERMINATION      2 z@KS   2 z@K  2 z@KAND  72 z@KAUTHORIZATION FOR RELEASE OF        g2 =@KMEDICAL RECORDS IN UM APPEALS AND INDEPENDENT ARBITRATION OF             @"Gill Sans MT--------- 2 u@KCLAIMS  ---  2 @K ---  2 @K  'K@Georgia---  2 WK  ' - @ !C8-  - @ !C8-  ```- @ !E:- - @ !E:-  - @ !I>-  - @ !I>-  - @ !C@-  ```- @ !E@-  - @ !I@-   - @ !C-  - @ !C-  ```- @ !E- - @ !E-  - @ !I-  - @ !I-     - @ !TK>-  ```- @ !TK:-  - @ !TK8-   - @ !8-  - @ !8-  ```- @ !:- - @ !:-  - @ !>-  - @ !>-  - @ !@-  ```- @ !@-  - @ !@-   - @ !TK-  ```- @ !TK-  - @ !TK-   - @ !-  - @ !-  ```- @ !- - @ !-  - @ !-  - @ !-     @Times New Roman- - -   2 00   --- 2 0 APPEALS OF U     2 * 0 TILIZATION     2 0 M  2  0 ANAGEMENT     2 0    2 0 DETERMINATIONS       2 j0   ---  2 00 Y 2 80 ou  %2 L0 have the right to  2 0   2 0 ask  p2 C0 your insurer, HMO or other company providing your health benefits (   2 S0 carrier  2 w0 )  2 {0    2 0 to change its  2  0 utilization   #2 00 management (UM)    2 0 decision  2 0   y2 I0 if the carrier determines that a service or treatment covered under your    :2 `0 health benefits plan is or was   @"Gill Sans MT- - - - - - ---- - - --- /2 00 not medically necessary.  - - -  0- - - 2 *'--- 2 0   72 0 This is called a UM appeal.   @2 m#0 You also have the right to allow a   22 50 doctor, hospital or other  2  0 health care   G2 0(0 provider to make a UM appeal for you.     2 0     2 00 T  2 80 here are three  2 0   2 0 appeal  2 0 stages  2 0   e2 <0 if you are covered under a health benefits plan issued in Ne   2 *0 w   2 30   2 80 Jersey. 2 Z0    2 d0 S 2 j0 tage  2 0   2 0 1:  2 0    2 0   )2 0 the carrier reviews    2 /0^0 your case using a different health care professional from the one who first reviewed your case    2 /:0 .   2 /G0 S 2 /M0 tage  2 /c0   2 /h0 2:  2 /r0    2 /w0   2 /| 0 the carrier  2 / 0 reviews your    2 >00 case  2 >L0 using  2 >m0 a panel  2 >0 tha 2 >0 t  2 >0 includ 2 >0 es  2 >0    2 >0 m  72 >0 edical professionals trained  2 >0 in  2 >0   2 >0 case  2 >0 s  2 >0   2 > 0 like yours.   2 >0 S 2 >0 tage  2 >0   2 >0 3:   2 >-0 y +2 >30 our case will be revi  2 >0 ew  2 >0 ed  2 >0   2 > 0 through the   2 N0k0 Independent Health Care Appeals Program of the New Jersey Department of Banking and Insurance (DOBI) using           2 N0 an  2 N 0 Independent   ;2 ]0 0 Utilization Review Organization    2 ]0 (IURO)    )2 ]0 that contracts with   ;2 ] 0 medical professionals whose prac   =2 ];!0 tices include cases like yours.  2 ]0 Th 2 ]0 e   +2 m00 health care provider  .2 m0 is required to attempt   2 m0 to  2 m(0   s2 m-E0 send you a letter telling you it intends to file an appeal before fil 2 m0 ing  2 m0   2 m 0 at each stage 2 m0 .   2 m0    2 m0    2 00 At S  2 J0 tage   2 g0 3 42 n0 , the health care provider  2  0 will   2 0   2 !0 share  2 >0   D2 D&0 your personal and medical information    2 $0 with   2 ;0    2 A0 D   2 K0 O  2 V0 BI  2 `0 ,  2 c0   2 i0 the  2 z0   2 0 IURO   2 0 , and t 2 0 he IURO   2 0 s  2 0    2 0 0 contracted  2 j0   2 o 0 medical pr  2  0 ofessional 2 0 s.  2 0 Everyone  2 !0   2 &0 is  2 .0   2 2 0 required  2 d0 by law   2 0 to  2 0 keep  2 0   %2 0 your information   2  0 confidential 2 T0 . DOBI   2 0 must   2 0   &2 0 report data about   Y2 040 IURO decisions, but no personal information is ever     2 N 0 included  %2 0 in these reports.  2 0    h2 0>0 You have the right to cancel (revoke) your consent at any time   2 0 . 2 0    2 0 Y 2  0 our financ G2 (0 ial obligation, IF ANY, does not change   2 0 because  2 0   2 0 you   2 0 0 choose to  #2 k0 give consent to   2 0 representation 82 0 , or later revoke your consent 2 0 .   2 0 Y 2  0 our consent  O2 -0 to representation and release of information    =2 0!0 for appeal of a UM determination    2  0 will end  2 0 24  2 $0   2 '0 months  2 T0 after  2 l0   2 q0 the  2 0 date  )2 0 you sign the consent  2 0 .  2 0   --- 2   0 INDEPENDENT      +2 t0 ARBITRATION OF CLAIMS         2 &0   --- 2 0Q0 Your health care provider has the right to take certain claims to an independent   2 0 claims   52 0 arbitration process through  2 0 the  2  0 DOBI. To   U2 010 arbitrate the claim(s), the health care provider   2 B 0 may share  P2 .0 some of your personal and medical information     2 0 with   2 0   2 0 the  2  0 DOBI, the   2 '00 ar ;2 '; 0 bitration organization, and the  52 '0 arbitration professional(s). 2 'u0   72 '0 Everyone is required to keep  2 ' 0 you  2 '40 r  2 '90   2 '= 0 information   2 '{0   "2 '0 confidential.  2 '0 The  2 '0 DOBI   2 700 report  2 7R0 s  2 7W0   U2 7]10 data about the arbitration outcomes, but no perso  82 7|0 nal information will be in the    2 70   2 7#0 report  2 7E0 s (2 7J0 . Your consent to  2 70 the  2 70 releas 2 70 e of  --- :2 F00 information for the arbitration   2 F0   %2 F0 process will end   2 F40 24  2 FB0   L2 FE+0 months after the date you sign the consent. ---  2 F00    22 ^c0 CONSENT TO REPRESENTATION         2 ^J0 IN UM APPEALS      2 ^0 AND   2 ^0 AUTHORIZATION    2 ^_0 TO   2 ^s0   2 ^x 0 RELEASE OF     2 m 0 INFORMATION     2 m#0   F2 m*'0 IN UM APPEALS AND ARBITRATION OF CLAIMS              2 mq0     2 00   ---@"Gill Sans MT- - - ---- - - ---@"Gill Sans MT- - - ---- - - ---- - - ---- - - --- 2 00 I,   2 ;0  % #2 `0  - - -  2 0 PRINT    2 0   2 0 NAME ---  2 0  '  2  0  0  2 P0  0  2 0 , by marking    2 0    2 0 v  2 0  - - -  2 0  --- 2 0 (or- - -  2 0    2 0  ---  2 0 x  2 0  - - -   2  0  --- 82 0 ) and signing below, agree to:   2 0   0-- @ !:-- @ !:-- @ !E;- - @ !-- @ !- - @ !:- - @ !- - @ !:-- @ !:-- @ !E;- - @ !-- @ !- - ' 0-- @ !-- @ !-- @ !- - @ !-- @ !- - @ !- - @ !- - @ !-- @ !-- @ !- - @ !-- @ !- - ' 0-- @ !-- @ !-- @ !- - @ ! -- @ ! - - @ !- - @ ! - - @ !-- @ !-- @ !- - @ ! -- @ ! - - '   0  0 '--=1- -'--- 2 ?0    2 J0 r 2 O 0 epresentation  2 0   2 0 by   2 0    2 0    2 0    2 0    2 0    2 0    2 0   42 0 in an appeal of an adverse  %2 g0 UM determination   2 0 as  2 0 allowed   2 0   2  0 by  2 0 N.J.S.A.    2 C0   2 G0 26:2S  2 e0 - 52 i0 11, and release of personal @ Gill Sans MT---- @ !(-  0-- @ !-- @ !-- @ !#- - @ !-- @ !- - @ !- - @ !- - @ !-- @ !-- @ !#- - @ !-- @ !- - ' --- 2 Iy0 health information to DOBI, its contractors for the Independent Health Care Appeals Program, and independent contractors         @2 I#0 reviewing the appeal. My consent    ,2 0 to representation and  %2 0 authorization of  .2 0 release of information   2 h0 exp 2 |0 ires in  2 0 24  2 0   2 0 months  2 0 , but I   ,2 I0 may revoke both sooner   2 0 .  2 0     0  0 '--=1- -'--- 2 ?0   2 In0 release of personal health information to DOBI, its contractors for the Independent Claims Arbitration Program        2 0   "2 0 or the Chapter    2 I0 32  82 \0 Independent Arbitration System   2  \0 , and any independent contractors that may be required to perform the arbitration process.     2 I0 My  #2 ]0 authorization of  2 0   .2 0 release of information   #2 20 for purposes of  2 0 claims   2  0 arbitration  "2 0 will expire in  2 40 24  2 B0   2 E0 months.   2 p0     2 &00     2 500    2 D0 0 Signature:  82 Dl0 ______________________________ 2 DD 0 _____________ 2 D 0   +2 D0 Ins. ID#:____________  2 DP0 __ 2 D^ 0   %2 D0 Date: __________   2 D0 _  2 D0    /2 T00 Relationship to Patient:  2 T0    0  0 '--VJ- -'---  2 T0   #2 T0 I am the Patient   2 T(0  (  0  0 '--V]JQ- -'---  2 T_0   2 Tc 0 I am the   2 T0 Personal  2 T0    2 T0 Representative  2 T0   2 T 0 (provide  42 TJ0 contact information on back   2 T0 )  2 T0   @Times New Roman---  0C2 ~0( 2 ~ '---  2 ~0  @Times New Roman---- @ !z0-  @Georgia--------------------- --- 0--- 2 0*'---  2 30  --- 2 60 If the  2 O}0 patient is a minor, or unable to read and complete this form due to mental or physical incapacity, a personal representative  ;2 i 0 of the patient may complete the   --------- 2 00 form.--- 2 G0    2 O0   "SystemvXDѵvvțP--  00//..TTdp՜.+,0< hp  SexyDOBI1 < QConsent to Representation in an Appeal of a Utilization Management Determination Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMOPQRSTUWXYZ[\]^_`abcdefghjklmnopqrstuvwxyz{|}~Root Entry F?C `Data N1TableVj%WordDocumentFSummaryInformation(iDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q