ࡱ> jliq` 5bjbjqPqP 4z::?T ,LT!(Ul8q s s s s s s $"hl$ 9"  pq q  0l8id 0!%f%% 3!D DDD  New Jersey Department of Banking and Insurance Notice of Intent to Appeal an Adverse UM Determination  Stage 3 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 Determination: FORMTEXT      Stage 1 Notice of Intent to Appeal: FORMTEXT      Stage 1 Decision: FORMTEXT      Stage 2 Notice of Intent to Appeal: FORMTEXT      Stage 2 Decision: FORMTEXT       Dear  FORMTEXT      : Health care services you received were determined by your carrier not to be medically necessary. We disagreed with the carriers determination, and filed a Stage 1 appeal. We appealed on your behalf based on the 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) you gave us. As required by law, we sent notice to you of our intent to file a Stage 1 appeal. The carrier issued a determination on the Stage 1 appeal and we still disagreed with the carriers determination. We provided notice to you of our intent to file a Stage 2 appeal, and then filed a Stage 2 appeal. The carrier has now issued a determination on the Stage 2 appeal, and we continue to disagree with the carriers decision. THIS IS NOTICE OF AN INTENT TO FILE A STAGE 3 APPEAL WITH THE INDEPENDENT HEALTH CARE APPEALS PROGRAM. There are three stages to the appeal process. In Stage 1, the carrier had a health care provider review your case again. The health care provider was not the same health care provider who originally denied the services. At Stage 2, the carrier had a panel review your case, including at least one health care provider familiar with the services for your condition. Because we still disagree with the carriers determination after the end of the Stage 2 appeal, we have decided to 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. The cost of filing an appeal is $25.00. We are solely responsible for the costs when we file on your behalf. 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 prior Consent and Authorization (include the date you signed the Consent and Authorization). In both instances, return any notice of revocation to: New Jersey Department of Banking and Insurance Consumer Protection Services ` $     2 4 ÷~v~kv]v~v~RjhsUjhsUmHnHujEhsUjhsUhsjhv%UmHnHujhv%Ujhv%Uhv%hh]h#%hOh#%hO5OJQJh\5OJQJhOhO5OJQJhOhOCJOJQJaJ0jhOhOCJOJQJUaJmHnHu `" $ . 0 P ` p x$a$gd#%$a$gda4Ybkd$$Ifl !064 laX $$Ifa$gd#% $IfgdO 55 D sg $$Ifa$gds$$If`a$gdsgkd$$Ifl$h% t0644 la $$Ifa$gd J$a$gda4Y4 6 @ B D Z \ p r t ~    " & X Z \ p r t ~   * ϼǮϣǮϞϓǮnjρǮnjj_hv%U h hv%jhv%U hv%6j"hv%Ujhv%UmHnHujhv%Ujhv%Uhv%j-h$U hshshsjhsUmHnHujhsU/ qee $$Ifa$gd Jkd$$IflF $a  a t06    44 la $ j^^ $$Ifa$gd Jkd$$Ifl0$  tsss0644 lapsss$ & xx $$Ifa$gd Jzkd$$Ifl0H$ t0644 la < xx $$Ifa$gd Jzkd$$Ifl0H$ t0644 la* , . 8 : < ^ ` t v x   . 0 2 < > B D N P d f h r t x z ~ ,-NӽӲӮ}y}u}y}hE;hMha4Yh0kjh#%UmHnHujh JUh#%jh#%Uhh5Kjh JUjah JUjhv%Uhv% h>hv%jhv%UmHnHujhv%Uj&hv%U. @ xx $$Ifa$gd Jzkd$$Ifl0H$ t0644 la@ B D x z | yz||||||pddd $`a$gdq< $`a$gd$a$gda4YzkdM$$Ifl0H$ t0644 la Njmvx&'AC\]l /2q?FwzqtO^)-FX -F &Hab4U hv%6 h)6h0kh)hq<hv% hE;6ha4YhE;6hE;hhOhMN&434J4_4443545y5z5{5555$a$gda4Y$^`a$gdH'$a$gd]$a$gdg\ $`a$gd] $`a$gd] $`a$gdq<Office of Managed Care Attn: IHCAP P.O. Box 329 Trenton, NJ 08625-0329 Fax: (609) 633-0807 Courier service: 20 West State Street In addition, we would appreciate a copy of the revocation as well. Even if you do not revoke your Consent and Authorization, it will expire two years after you signed it. 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