State of New Jersey

DEPARTMENT OF BANKING AND INSURANCE

OFFICE OF THE COMMISSIONER

PO BOX 325

TRENTON, NJ 08625-0325

TEL (609) 292-7272

PHIL MURPHY

Governor

SHEILA OLIVER

Lt. Governor

MARLENE CARIDE

Commissioner

BULLETIN NO. 20-08

TO: ALL NEW JERSEY LICENSED INSURANCE COMPANIES, MEDICAL SERVICE COPORATIONS, HOSPITAL SERVICE CORPORATIONS, HEALTH MAINTENANCE ORGANIZATION, ORGANIZED DELIVERY SYSTEMS, OTHER ENTITIES THAT ISSUE FINAL ADVERSE BENEFIT DETERMINATIONS, HEALTH CARE PROVIDERS, COVERED PERSONS, AND OTHER INTERESTED PARTIES

FROM: MARLENE CARIDE, COMMISSIONER

RE: TEMPORARY EXTERNAL APPEAL APPLICATION PROCEDURES FOR THE INDEPENDENT HEALTH CARE APPEALS PROGRAM

On March 9, 2020, Governor Phil Murphy declared a state of emergency and public health emergency through the issuance of Executive Order No. 103 ("EO 103") to contain the spread of the Coronavirus ("COVID-19") pandemic. As the State responds to the COVID-19 pandemic, the Department of Banking and Insurance ("Department") is issuing this Bulletin to provide guidance to all health insurance companies, medical service corporations, hospital service corporations, health maintenance organizations, organized delivery systems, and other entities that issue final adverse benefit determinations in this State (collectively "carriers"), as well as health care providers, covered persons, and other interested parties, regarding temporary procedures for the filing of External Appeal Applications for the Independent Health Care Appeals Program, pursuant to N.J.S.A. 26.2S-11, N.J.A.C. 11:24-8.7, and N.J.A.C. 11:24A-3.6.

Effective immediately and continuing for the duration of the state of emergency and public health emergency declared pursuant to EO 103, the Department is modifying the requirement set forth in N.J.A.C. 11:24-8.7(b) and N.J.A.C. 11:24A-3.6(b), which provides that appeals of a final internal adverse benefit determination must be submitted to the Department by mail or fax. The Department is now temporarily requiring that external appeals be submitted to the Department by email to ihcap@dobi.nj.gov. The temporary, modified External Appeal Application form is annexed to this Bulletin and should be used immediately for all external appeals filed through email in response to this Bulletin.

Additionally, the Department is immediately, for the duration of the state of emergency and public health emergency declared pursuant to EO 103, suspending the requirement set forth in N.J.A.C. 11:24-8.7(c) and N.J.A.C. 11:24A-3.6(c), which provides that covered persons or health care providers acting on a covered person's behalf must pay a $25 filing fee, payable by check or money order to the Department. As the Department is requiring that all external appeals be submitted through email, rather than mail or fax, the Department is suspending this filing fee for all External Appeals Applications submitted through email in response to this Bulletin.

Carriers are also advised that they must immediately, for the duration of the state of emergency and public health emergency declared pursuant to EO 103, alter the external appeal instructions that are issued with a final internal adverse benefit determination to reflect that External Appeal Applications must be submitted to the Department through email to ihcap@dobi.nj.gov rather than by mail or fax and that payment of the $25 filing fee is suspended for the duration of the state of emergency.

For help completing the External Appeal Application annexed hereto, please contact the Department's Consumer Inquiry and Response Center at (800) 446-7467 or (609) 292-7272.

3/24/20

Date

___________________________________

Marlene Caride

Commissioner

AV COVID-19 External Appeals Bulletin/COVID-19

Forms

STATE OF NEW JERSEY

DEPARTMENT OF BANKING AND INSURANCE

NOTICE OF RULE WAIVER/MODIFICATION/SUSPENSION

PURSUANT TO EXECUTIVE ORDER NO. 103 (MURPHY) (MARCH 9, 2020)

COVID-19 STATE OF EMERGENCY

Temporary Rule Modification and Suspension adopted by Marlene Caride, Commissioner, Department of Banking and Insurance

Date: March 19, 2020

Authority: N.J.S.A. App.A:9-45 & App. A:9-47; Executive Order No. 103 (Murphy) ("EO 103")

Effective Date: March 19, 2020

Expiration Date: Concurrent with expiration of EO 103

This is an emergency adoption of a temporary rules modification of the Department of Banking and Insurance's Division of Insurance rules at N.J.A.C. 11:24-8.7(b) and N.J.A.C. 11:24A-3.6(b) and temporary rules suspension of the Department of Banking and Insurance's Division rules at N.J.A.C. 11:24-8.7(c) and N.J.A.C. 11:24A-3.6(c). Section 6 of EO 103, issued in response to the COVID-19 pandemic, authorizes agency heads to waive/suspend/modify any existing rule, where the enforcement of the rule would be detrimental to the public welfare during the emergency, notwithstanding the provisions of the Administrative Procedure Act or any law to the contrary. Pursuant to that authority, and with the approval of the Governor and in consultation with the State Director of Emergency Management and the Commissioner of the Department of Health, the Department of Banking and Insurance is modifying and/or suspending its rules as follows:

In an effort to provide for the timely processing of External Appeals Applications for the Independent Health Care Appeals Program, pursuant to N.J.S.A. 26:2S-11, N.J.A.C. 11:24-8.7, and N.J.A.C. 11:24A-3.6, during the COVID-19 pandemic, the Department is taking the following action:

N.J.A.C. 11:24-8.7(b) and N.J.A.C. 11:24A-3.6(b), which provide that appeals of a final internal adverse benefit determination must be submitted to the Department by mail or fax, are modified to require that external appeals be submitted to the Department by email to ihcap@dobi.ni.gov. rather than mail or fax.

N.J.A.C. 11:24-8.7(c) and N.J.A.C. 11:24A-3.6(c), which provide that covered persons or health care providers acting on a covered person's behalf must pay a $25 filing fee, payable by check or money order to the Department, are suspended for the duration of the state of emergency.

I find that modification of the rules N.J.A.C. 11:24-8.7(b) and N.J.A.C. 11:24A-3.6(b) and the suspension of the rules N.J.A.C. 11:24-8.7(c) and N.J.A.C. 11:24A-3.6(c) above is necessary because enforcement of the existing rules would be detrimental to the public welfare during this emergency.

3/24/20

Date

___________________________________

Marlene Caride,

Commissioner of Banking and Insurance

AV COVID-19 External Appeals Modification and Suspension Notice/COVID-19