ࡱ> q` ibjbjqPqP .t::7***8+l+zB>,11112 3q4TAAAAAAA$0ChEA82288A114BU=U=U=8X11AU=8AU=U=U=12, O}*]8XU=u= JB0zBU=F8HFU=FU= 4v;5TU=5D52444AA<X444zB8888^^4B New Jersey Department of Banking and Insurance Summary Description of Patient Appeal Process HEALTH CARE QUALITY ACT REGISTRATION In accordance with N.J.S.A. 26:2S-3 and N.J.A.C. 8:38A-2.2, carriers shall complete and submit an HCQA Registration form at least 30 days prior to the date that the carrier will begin to offer any health benefits plan issued under a policy or contract form for which an HCQA Registration form has not previously been filed. In addition, a carrier shall complete and submit an HCQA Registration form no later than 10 business days following the date of any substantive change to the information regarding a health benefits plan policy or contract contained in the carriers prior HCQA Registration form filing. Business days include 8:00 AM Monday through 5:00 PM Friday, excluding any holiday recognized by the ǿ޴ýapp through closure of its business offices. NOTE: Affiliated companies should submit separate HCQA Registrations, completed only for their own contract forms. NOTE: Failure to submit this form may result in fines and other penalties. Submit by mail to: New Jersey Department of Banking and Insurance Valuation Bureau PO Box 325 Trenton, NJ 08625-03251. CARRIER INFORMATIONName of Carrier  FORMTEXT      NAIC Number  FORMTEXT      Address  FORMTEXT      Type of Carrier  FORMCHECKBOX Insurer  FORMCHECKBOX Health Service Corporation  FORMCHECKBOX Hospital Service Corporation  FORMCHECKBOX Medical Service Corporation  FORMCHECKBOX Dental Service Corporation  FORMCHECKBOX Dental Plan Organization2. CONTACT INFORMATIONName of Contact Person  FORMTEXT      Title of Contact Person  FORMTEXT      Mailing Address  FORMTEXT      Telephone Number  FORMTEXT      Fax Number  FORMTEXT      E-mail Address  FORMTEXT       HEALTH CARE QUALITY ACT REGISTRATION Continued 3. PRODUCT IDENTIFICATIONA. Complete the table below for all health benefits plans that incorporate utilization management features and/or are managed care plans. Attach more pages as necessary.Form NumberProduct Name and Type (Examples of Product Type: Indemnity, SCA, PPO, HMO)Utilization Management1Managed Care Plan2YesNoYesNo FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT   / 6 8 F ~ (*,68LNbdfpr02̰̰̰rjh>CJUj>h>CJUjh>CJUj\h>5Ujdh>5Ujh>5UmHnHujh>5Ujh>5U h>5CJ h>5CJh> huCJ h>CJ h>CJ h>5,/]  8 N ~ }$ F$If]^a$$ F$If]^a$$ h$If]^a$$ x$If]^a$$ $If]^a$x$a$ 8ii~ :{o{o x$If^$If;kd|$$IfTH4 )0*4 Haf4T $$Ifa$8kd$$IfTH)0*4 HaT:<Ltv^XLL x$If^$If;kd$$IfTH4@)0*4 Haf4T$If]^x$IfNkd$$IfTH400) 4 Haf4T2NPRz|02FHJTVжЦtgtjLh>5Ujh>5UmHnHujh>5U h>5jh>5U h>5CJjhuh>CJUjhuh>CJUjhuCJU huCJjh>CJUjh>CJUj&h>CJU h>CJ'0X~xlxl x$If^$If;kdd$$IfTH4 )0*4 Haf4T $$Ifa$;kd$$IfTH4)0*4 Haf4TF\^XLXL x$If^$If;kd$$IfTH4@)0*4 Haf4T$If]^x$IfNkd$$IfTH400)4 Haf4T 468BD\^rtv.df_`  ϵϨԢԐԉԂԂuj h>5U h>CJH* h>6CJ h>5CJ h>5CJh> h>CJj h>5Uj h>5Uj h>5U h>5 h>CJjh>5UmHnHujh>5Uj6h>5U..dx $$Ifa$akdt $$IfTH40F` )      4 Haf4T x$If^$Ifdf_`lulllll $$Ifa$;kdt $$IfTH4D)0*4 Haf4T @$If] ^@`;kd $$IfTH4 )0*4 Haf4T $$Ifa$tkd $$IfTH4\XH$)P4 Haf4T6Xzd[M[[[[$If]^ $$Ifa$kd $$IfTH4ֈXx!H$')4 Haf4T$&(2468LNPTVXZnprvxz| jh>5Uj8h>5U h>CJj h>5Ujh>5Ujh>5Ujh>5Ujh>5UmHnHuj2h>5U h>5jh>5U22Tvd[M[[[[$If]^ $$Ifa$kd$$IfTH4 ֈXx!H$')P4 Haf4T&(*.024HJLPRTVjlnrtvx  jh>5Uj*h>5Ujh>5U h>CJjh>5Ujh>5Ujh>5Ujh>5UmHnHuj$h>5U h>5jh>5U2 .Prd[M[[[[$If]^ $$Ifa$kd$$IfTH4 ֈXx!H$')P4 Haf4T "$&*,.0DFHLNPRfhjnprtvjh>5Ujh>5Ujh>5Uj0h>5U h>CJjh>5Ujh>5Ujh>5UmHnHujh>5U h>5jh>5U2rt*Ld[M[[[[$If]^ $$Ifa$kdx$$IfTH4 ֈXx!H$')P4 Haf4T  "&(*,@BDHJLNPdfhrtvxjh>5Ujh>5Ujh>5Uj"h>5Ujh>5U h>CJj~h>5Ujh>5UmHnHujh>5U h>5jh>5U2LNv&d[M[[[[$If]^ $$Ifa$kd$$IfTH4 ֈXx!H$')P4 Haf4T"$&(*>@BLNPRfhjtvxzjv!h>5Uj!h>5Uj h>5Uj h>5Ujh>5Uj(h>5U h>CJjh>5UmHnHujh>5U h>5jh>5U2&(Pxd[M[[[[$If]^ $$Ifa$kdp$$IfTH4 ֈXx!H$')P4 Haf4T*Rtd[M[[[[$If]^ $$Ifa$kd!$$IfTH4 ֈXx!H$')P4 Haf4T&(*,@BDNPRThjlprtvj &h>5Uj$h>5Uj|$h>5Uj$h>5Uj#h>5Uj#h>5Ujh>5UmHnHuj"h>5U h>5jh>5U h>CJ2,Npd[M[[[[$If]^ $$Ifa$kdh%$$IfTH4 ֈXx!H$')P4 Haf4T(*,.BDFJLNPdfhlnprj*h>5Uj)h>5U h>CJjn(h>5Uj'h>5Uj'h>5Uj 'h>5Ujh>5UmHnHuj&h>5Ujh>5U h>52(Jld[M[[[[$If]^ $$Ifa$kd($$IfTH4 ֈXx!H$')P4 Haf4T $&(*>@BFHJL`bdhjlnj.h>5Uj-h>5Uj-h>5U h>CJj+h>5Ujt+h>5Uj*h>5Ujh>5UmHnHuj*h>5Ujh>5U h>52Z$ZFZhZd[M[[[[$If]^ $$Ifa$kd`,$$IfTH4 ֈXx!H$')P4 Haf4T FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   B. Attach a copy of the certificate or handbook language describing the internal patient appeal process available to covered persons under the above-listed contract forms to contest an unfavorable utilization review decision, such as a denial, reduction or termination of benefits or services. If your company has materially different appeal processes for certain of the contract forms listed, please attach the certificate or handbook language for these separately, and indicate clearly which process applies to which contract forms. If you believe any variable text contained in the form requires explanation, please include an explanation with the form.________________________________ 1 The term  utilization management means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid form, or otherwise provided under the health benefits plan. The system may include: preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory care procedures and retrospective review. 2 The term  managed care plan means a health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangements with participating providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating providers and procedures provided for in the plan.     MC-15 DEC 05 Page  PAGE 1 of 2 Pages. 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