ࡱ> cebq` 0bjbjqPqP 4r::C ?T@$d<R(zzzYtL(SUUUUUU$hNy9A7"YAAyzzApzzSASz י8d0   AAAAAAAyyAAAAAAA   New Jersey Department of Banking and Insurance Notice of Intent to Appeal an Adverse UM Determination  Stage 1 Name of Health Care Provider Date Name of Patient Address Address Address Insurance Carrier: FORMTEXT      Ins. ID: FORMTEXT      Claim No: FORMTEXT      Med Record:  FORMTEXT      DATE OF: Service/Admission: FORMTEXT      Discharge: FORMTEXT      Consent and Authorization: FORMTEXT      UM decision: FORMTEXT       Dear  FORMTEXT      : Health care services you received have been determined by your carrier not to be medically necessary. We disagree with the carriers determination. At the time you received health care services from us, you provided us with a signed Consent to Representation in Appeals of Utilization Management Determinations and Authorization of Release of Medical Records in UM Appeals and Arbitration of Claims (Consent and Authorization). This Consent and Authorization allows us to file an appeal of the carriers utilization management (UM) determination on your behalf. However, we must attempt to provide you with notice before filing at any stage of the appeal process. THIS IS NOTICE OF AN INTENT TO FILE A STAGE 1 APPEAL. There are three stages to the appeal process. In Stage 1, the carrier will have a health care provider review your case again. The health care provider is not the same health care provider who originally denied the services. If, after the Stage 1 ends, we still think the carriers determination is incorrect, we will have the option to file a Stage 2 appeal. At Stage 2, the carrier will have a panel review your case, including at least one health care provider familiar with the services for your condition. If we still disagree with the carriers determination after the end of the Stage 2 appeal, we may file an appeal with the New Jersey Department of Banking and Insurances Independent Health Care Appeals Program (IHCAP). The IHCAP contracts with Independent Utilization Review Organizations (IUROs). The Consent and Authorization allows us to ask for a review by an IURO, and to share your personal health information with employees at the New Jersey Department of Banking and Insurance, the IURO, and with the IUROs health care providers as necessary for the appeal to be processed and reviewed. However, your information will be treated confidentially in all instances. You may revoke or cancel your Consent and Authorization at any time by completing the back page of the copy of the Consent and Authorization which we gave to you for your records. Or, you may write your own note simply saying that you revoke your Consent and Authorization (include the date you signed the Consent and Authorization). In both instances, return any notice of revocation to the carrier indicated above. In addition, we would appreciate a copy of the revocation. Even if you do not revoke your Consent and Authorization, it will expire two years from the date you signed it. 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