What to do when you don't agree with a decision made by WellChoice
WellChoice strives to ensure members have access to the appropriate care and services. If you do not agree with a WellChoice decision, you are entitled to file an Appeal or Grievance. Here is a description of the Appeal and Grievance processes. Remember that you need to file First Stage Appeals and Grievances within 180 calendar days from the date of WellChoice's initial decision.
A Grievance is a verbal or written request to review an adverse determination concerning an administrative decision not related to medical necessity (i.e. claim denial). If you are not satisfied with the decision made on your First Stage Appeal you may request a Second Stage Appeal within 60 business days of the previous decision.
Grievances are investigated and resolved within 15 days if services have not yet been rendered and within 30 days if services have already been rendered.
You can request an
Expedited Grievance and receive a quicker response if a delay in resolution of the grievance would pose an imminent or serious threat to your health. WellChoice makes a decision within 72 hours of receipt of the grievance.
If you are not satisfied with the decision made at the First level of Grievance you may request a second Grievance within 60 business days of the previous decision.
Second Grievances are resolved within the same timeframes as the First Grievance and are reviewed by individuals not involved in the previous decisions
An Appeal: is a verbal or written request to review and change an adverse determination made by WellChoice's Medical Management Program or Behavioral Healthcare Management Program that a service is not medically necessary or is excluded from coverage because it is considered experimental or investigational.
Stage One Appeals are investigated and resolved within 5 business days. You receive a letter that documents the decision. If the adverse determination was partially or fully upheld, you receive an explanation of the decision, as well as further appeal rights, in the letter.
You can request a quicker response through an
Expedited First Stage Appeal if a delayed decision would pose an imminent or serious threat to your health.
WellChoice makes a decision within 72 hours of receipt of the Expedited Appeal.
If you are not satisfied with the decision made on your First Stage Appeal you may request a Second Stage Appeal within 60 business days of the previous decision.
Second Stage Appeals are resolved within 15 calendar days of receipt for pre-service appeals, and 20 business days of receipt for post-service appeals. They are reviewed by individuals not involved in the previous decisions, and you may request a consultation on the appeal by a practitioner of the same specialty as would typically manage the case at issue. You receive a letter that documents WellChoice's decision on the appeal. If the adverse determination was partially or fully upheld, you receive an explanation of the decision, as well as further external appeal rights, in the letter.
Second Stage Appeals are resolved within 72 hours of receipt if a delay would a pose serious threat to a member's health (or if the patient was confined in an inpatient facility).
Please note: If you are dissatisfied with the outcome of a Second Stage Appeal that a service is not medically necessary or is excluded from coverage because it is considered experimental or investigational, you may request an External Review by an independent utilization review organization within 60 calendar days of receiving the Stage 2 adverse determination. You may also proceed to an external appeal if WellChoice does not complete your appeal in the timeframes documented here. Specific instructions regarding how you may pursue an external review and the forms required to initiate the review are provided with the Second Stage Appeal denial notification. For more details, see the explanation below about External Review.
An External Review is performed by an independent review agent designated by the New Jersey Department of Health and Senior Services, when requested by the member or a provider acting with your consent.
You can file an External Appeal if benefits were denied
- for lack of medical necessity
- because the service was determined to be an experimental and/or investigational procedure.
An External Review is not available for benefits denied reasons other than those above.
