樱花视频

• How to file a Managed Care Complaint
• Browse our Frequently Asked Questions
• Definitions and Acronyms

Every person covered under a managed care plan has the right to file a complaint with his carrier about any aspect of the coverage, the carrier's network, and the services provided by health care providers. If the individual prefers, he may have his health care provider file the complaint instead, if the individual gives consent, and the health care provider agrees to do so.

A carrier is required to respond to complaints filed by or on behalf of its covered individual within a reasonable period of time up to 30 days after the date the carrier received the complaint. Carriers are required to establish a complaint system, and to provide covered individuals a written explanation about the process for filing a complaint. Generally, this information will be contained in a member handbook or certificate of coverage, but it may be provided separately. The information should include the telephone number and address of the carrier's offices responsible for complaint resolution. In addition, the information must advise covered individuals of their right to contact the 樱花视频 Department of Banking and Insurance (Department), in the event that the covered individual is not satisfied with how the carrier handled the complaint.

The Department has an office within Consumer Protection Services that handles complaints from consumers and health care providers regarding coverage and/or payment under a managed care plan, including: complaints primarily concerning quality of care, choice and accessibility of health care providers, issues relating to the adequacy of the carrier's networks, and claims payment practices. The Department also addresses complaints regarding marketing practices, and policy provisions, but these complaints may be handled by a different office within Consumer Protection Services.

For a large group contract (employers with more than fifty employees), a pre-existing condition exclusion is permitted only if the exclusion relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the six month period prior to enrollment. The exclusion period must not exceed twelve months (eighteen months for late enrollees). The exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date. A pre-existing condition exclusion may not be imposed on newborns, adopted children or children placed for adoption under certain circumstances. Pregnancy may not be considered as a pre-existing condition. In the small employer market (employers with two to fifty employees), a pre-existing condition exclusion period is permitted only for groups of two to five employees and for "late enrollees," that is, an employee or dependent who fails to enroll for coverage within thirty days of being offered coverage. Further, for groups of two to five employees and late enrollees, a pre-existing condition exclusion period is permitted only if the exclusion relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the six month period prior to enrollment. Pregnancy may not be considered as a pre-existing condition. The exclusion period may not exceed six months. The exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date so long as replacement coverage is obtained within ninety days of the termination of the prior coverage.

For individual contracts (for individuals and their families), a pre-existing condition exclusion is defined more broadly than in the small and large employer markets and also includes a condition for which a reasonable person would have sought treatment even if treatment was not recommended or received. Further, pregnancy may be considered a pre-existing condition. The exclusion period for a pre-existing condition may not exceed twelve months, and the exclusion period is reduced by the aggregate of the periods of creditable coverage earned prior to the enrollment date so long as replacement coverage is obtained within 31 days of the termination of the prior coverage, or 63 days if the person had 18 months of continuous group coverage and has exhausted any continuation rights under the group plan.

CONTESTED CLAIM

A claim that has not been adjudicated because it has a material defect or impropriety.

樱花视频 Department of Human Services.

A benefits plan which pays for or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this state by or through a carrier. HBP includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. HBP shall not include the following plans, policies or contracts: accident only, credit, disability, long term care, CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection issued pursuant to N.J.S.A. 39:6A-1 et seq., or hospital confinement indemnity coverage.

Any organization which directly or through contracts with providers furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographic area.

An HMO with a COA to transact business in 樱花视频 that is no longer marketing to prospective members.

Association of individual physicians that provides services on a negotiated capitation rate, fee-for-services basis, or flat retainer fee.

A health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangement with participating providers, who are selected to participate on the basis of explicit standards, to furnish a specified set of health care services, and includes financial incentives for covered persons to use participating providers.