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Managed Care Consumer Rights

If you are covered under a managed care plan subject to the Health Care Quality Act (HCQA), N.J.S.A. 26:2S-1 et seq., and rules implementing that law, you have certain rights. If your policy is subject to the HCQA, you have:

1. The right to information about what health care services are covered and any limitations on that coverage.
2. The right to obtain a current directory of doctors within the network for your health benefits plan.
3. The right to obtain information about how network doctors are paid by your carrier.
4. Often, the right to obtain information about whether a referring doctor has a financial interest in the facility or services to which a referral is being made.
5. The right to change primary care providers (if you had to select one) without having to wait more than two weeks for the change to be effective.
6. The right to access a primary care provider 24 hours a day, 365 days a year for urgent care.
7. The right to call 911 in a potentially life-threatening situation without prior approval.
8. The right to go to an emergency room without prior approval when it appears to you that serious harm could result from not obtaining immediate treatment.
9. The right to have the carrier cover the emergency room medical screening exam that was necessary to determine whether an emergency medical condition exists.
10. The right to a choice of participating specialists within a carrier's network for referrals.
11. The right to a referral to a specialist with experience in dealing with your situation, if you have a chronic disability.
12. The right to all information that your doctor may think appropriate regarding your diagnostic and treatment options, even if the options are not all covered services under your policy.
13. The right to an explanation why approval of a covered services requested by you or your doctor was denied or limited by your carrier.
14. The right to know that the person denying or limiting a covered service is a doctor.
15. The right to file an internal Stage 1 and Stage 2 appeal of a carrier's decision to deny or limit a covered service, or to have your health care provider file the appeal on your behalf with your written consent, if your health care provider agrees to do so.
16. The right to receive appeal decisions in writing within specified timeframes, explaining why the carrier is upholding all or part of its prior decision, if it does so, and explaining what the next steps in the appeal process are, including provision of a form for filing an appeal with the Independent Health Care Appeal Program (IHCAP).
17. The right to file an appeal with the Independent Health Care Appeal Program for an independent, external review of the decision to deny or limit covered services.
18. The right to file a complaint with the carrier regarding any aspect of the carrier's operations, or to have your health care provider pursue the complaint on your behalf with your written consent, if your health care provider agrees to do so.
19. The right to file appeals and complaints without fear of retaliation against you or your health care provider.
20. The right to sue your carrier for losses if you sustain serious injury or death that you believe is the result of the carrier's denial or delay of approval of medically necessary covered services.

If the policy is delivered in a State other than New Jersey, or the policy is self-funded by an employer or employee organization, the HCQA does not apply, but you may have other rights under federal laws or the laws of another state. If you are covered under Medicare Advantage or Medicaid managed care plan or certain NJ FamilyCare plans, you may have rights in addition to those listed above. It is important to know what type of policy you are covered under, and the rights and responsibilities arising from that coverage.
OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.
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New Jersey Department of Banking and Insurance