Anyone who has been informed that a medically necessary service was terminated, denied, or the number of previously approved hours were reduced (e.g., private duty nursing hours) has the right to file an appeal. One type of
appeal is an HMO Plan Process appeal. The vast majority of persons with DD also have the right to request a Medicaid fair hearing (if you choose to begin with the Plan Process appeal, you can leave that appeal process at any stage and pursue the Medicaid fair hearing process instead).

• Plan Process: To request a Stage 1 appeal, call or write the HMO within 60 days of the date of the denial letter (if you begin with a phone call, you must follow up with a letter). When filing an appeal you have the right to continue the service that the HMO has terminated or reduced, but this request must be made, in writing, within 10 days of the date of the initial denial letter.

  If the Stage 1 appeal decision is unsatisfactoy, you can request a Stage 2 appeal by calling or writing the HMO (again, phone calls must be followed up with a letter) within 60 days of the date of the denial letter.

  If the Stage 2 appeal is unsatisfactory, you can request a Stage 3 external appeal. For this, you must complete some forms and send a filing fee of $2.00 to the New Jersey Department of Banking and Insurance within 60 days of the date of the denial letter.

• Medicaid Fair Hearing
  A written request for a Medicaid Fair Hearing must be made within twenty (20) days of the date of the denial letter. If you want to continue receiving services during the appeal, you will need to request this again within ten days of the date of the most recent denial letter from the plan process. After you request a fair hearing, the New Jersey Office of Administrative Law will schedule a Fair Hearing, where you will have the opportunity to present your case before an independent Administrative Law Judge.