Providers

Medicaid: Our Appeal Process is Changing

Dear Provider:

Thank you for being our provider!

Beginning July 1, 2017, the New Jersey Managed Care Organization appeal process for denials of health care services will be different because of changes to the federal rules that we must follow. Here are the highlights:

• The timeframe to request an Internal (Stage 1 or Level 1) Appeal will be shortened to 60 calendar days  (from 90 days);
  
  
• The Stage 2 or Level 2 Appeal will be eliminated;
  
  
• The timeframe to request an Independent Utilization Review Organization (IURO) Appeal (previously known as a Stage 3 or Level 3 Appeal) will be shortened to 60 calendar days (from four months);
  
  
• The Timeframe to request a Medicaid Fair Hearing will be extended to 120 calendar days (from 20 calendar days)

Please be assured that, should your patient, our member, need to request an appeal for a denial of a health care service, they will receive the appropriate letter from us at each stage or level of your appeal. The letters will guide them through the process. You can file an appeal on behalf of the member with written consent. You can also call us if you have any questions.

If you have any questions now, or require further information, please call us at (1-888-453-2534; TTY: 1-877-247-6272).

Again, thank you for being our provider.

Sincerely,

WellCare Health Plans of New Jersey