N.J. Admin. Code § 17:9-1.3

Current through Register Vol. 56, No. 23, December 2, 2024

Section 17:9-1.3 - Appeals from Commission decisions

(a) Any member of the SHBP who disagrees with the decision of the carrier and has exhausted all appeals within the plan, as well as any external review required by the PPACA, if applicable, may request that the matter be considered by the Commission. Requests for consideration must be directed to the Secretary of the Commission within one year of the plan's final adverse benefit determination, and must contain the reason for the disagreement and all available supporting documentation. Appeals shall be considered at the regular meetings of the Commission. It shall be the responsibility of the member to provide the Commission with any medical or other information that the Commission may require in order to make a decision.

(b) Any person who disagrees with a determination made by the Division regarding their enrollment or eligibility in the SHBP, may request that the matter be considered by the Commission.

(c) Notification of all Commission decisions will be made in writing to the member and the following statement shall be incorporated in every written notice setting forth the Commission's determination in a matter where such determination is contrary to the claim made by the claimant or his or her legal representative:

"If you disagree with the determination of the Commission in this matter, you may appeal by sending a written statement to the Commission within 45 days from the date of this letter informing the Commission of your disagreement and all of the reasons therefor. If no such written statement is received within the 45-day period, this determination shall be considered final."

(d) If a member disagrees with the Commission's decision and submits the written statement set forth in (c) above within 45 calendar days, the Commission shall determine whether to grant an administrative hearing on the basis of whether the matter involves contested facts or is solely a question of law. The Commission will then notify the member of the disposition of the appeal.

1. If the appeal involves solely a question of law, the Commission shall likely deny an administrative hearing request. If the request for an administrative hearing is denied, the Commission shall issue detailed findings of fact and conclusions of law. These findings and conclusions shall become the Commission's final administrative determination that may then be appealed to the Superior Court, Appellate Division.

2. If the appeal involves disputed facts, the Commission shall approve an administrative hearing request and transmit the matter to the Office of Administrative Law. Upon completion of this hearing, the Administrative Law Judge will submit to the Commission an initial decision that the Commission may adopt, reject or modify. If the Commission rejects or modifies the initial decision, it shall issue detailed findings of fact and conclusions of law that will become the Commission's final administrative determination that may then be appealed to the Superior Court, Appellate Division.

N.J. Admin. Code § 17:9-1.3

Amended by 48 N.J.R. 2387(a), effective 11/7/2016