Independent Health Care Appeals Program definition

Independent Health Care Appeals Program. IHCAP”)” means a program administered by the Department that provides for an external review by an Independent Utilization Review Organization of a carrier’s final coverage decision based on medical necessity or appropriateness of services.
Sample 1Sample 2Sample 3
Independent Health Care Appeals Program means the external appeals process for a Covered Person or provider on behalf of the Covered Person with the Covered Person's consent, to appeal a decision of a carrier to deny, reduce or terminate services or payment of benefits resulting from a decision by a carrier with respect to the Covered Person which services are otherwise covered under the health benefits plan. Independent Utilization Review Organization (IURO): means an independent organization with which the Department contracts to provide independent reviews through the Independent Health Care Appeals Program of carrier determinations regarding Medical Necessity or appropriateness of services which are contested by the Covered Person or a provider on behalf of the Covered Person..
Sample 1Sample 2Sample 3
Independent Health Care Appeals Program means a program administered by the Department which provides for a review by an Independent Utilization Review Organization.
Sample 1Sample 2Sample 3

Examples of Independent Health Care Appeals Program in a sentence

  • If the determination is to uphold the denial, the covered person and the covered person’s physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable.

  • Participating Provider acting on behalf of a Member with the Member’s consent, may appeal a final internal Adverse Benefit Determination, except where the final internal Adverse Benefit Determination was based on eligibility, including rescission, or the application of a contract exclusion or limitation not related to Medical Necessity, through the Independent Health Care Appeals Program to an independent utilization review organization (“IURO”).

  • Any stage 3 external appeal through the Independent Health Care Appeals Program must be filed within four (4) months of receipt of the final internal Adverse Benefit Determination.

  • If the determination is to uphold the denial, the covered person and the covered person’s physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S- 13) and N.J.A.C.11:24A-3.6, as applicable.

  • No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection.

  • You are not required to exhaust the Level One and Level Two appeals process before contacting the New Jersey Department of Banking and Insurance.Unless serious or significant harm has occurred or will imminently occur to you, you must exhaust an appeal through the Independent Health Care Appeals Program before you establish any litigation; arbitration; or administrative proceeding; regarding an alleged breach of the policy terms by HMO; or any matter within the scope of the appeals procedure.

  • In the event that an appeal instituted by a Network Provider on behalf of a Participant will be entertained as a member utilization management appeal without the Participant’s consent, the provision shall explain that such appeals will not be eligible for the Independent Health Care Appeals Program, established pursuant to N.J.S.A. 26:2S-11, until the Participant’s specific consent to the appeal is obtained.

  • See N.J. Dep’t of Banking & Ins., Independent Health Care Appeals Program, available at http://www.nj.gov/dobi/division_insurance/managedcare/ihcap.htm.

  • The bill requires a carrier that makes a utilization management decision with respect to the denial, reduction or termination of a health care benefit or the denial of payment for a health care service to provide the covered person with a notice informing the person of the person’s right to appeal and the procedure for initiating an appeal of the utilization management decision or denial of payment, and the procedure to initiate an appeal through the Independent Health Care Appeals Program.

  • Either Dental Office or LIBERTY may initiate an arbitration proceeding on or before the 90th calendar day following receipt of the determination which is the basis of the appeal, by submitting the DOBI form and all required information and documentation for submission of a claim to the Independent Health Care Appeals Program.

Related to Independent Health Care Appeals Program

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Non-Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has not been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Health care decision means any decision regarding the health care of the prospective donor.

  • Licensed health care provider means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.

  • Managed care plan means a health benefit plan that either requires a covered person to use, or

  • Independent educational evaluation means an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.

  • Licensed health care professional means a person who possesses a professional medical license that is valid in Oregon. Examples include, but are not limited to, a registered nurse (RN), nurse practitioner (NP), licensed practical nurse (LPN), medical doctor (MD), osteopathic physician (DO), respiratory therapist (RT), physical therapist (PT), physician assistant (PA), or occupational therapist (OT).

  • Managed Care Plans means all health maintenance organizations, preferred provider organizations, individual practice associations, competitive medical plans and similar arrangements.

  • Dependent care assistance program or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

  • Emergency medical care provider means an individual who has been trained to provide emergency and nonemergency medical care at the first responder, EMT-basic, EMT-intermediate, EMT-paramedic, paramedic specialist or other certification levels recognized by the department before 1984 and who has been issued a certificate by the department.

  • Child Care Program means a person or business that offers child care.

  • Medicare Advantage plan means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

  • Qualified mental health professional means a licensed medical practitioner or any other person meeting the qualifications specified in OAR 309-019-0125.

  • Non-Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Managed health care system means: (a) Any health care

  • Non-Administrator Coordinated Home Care Program means a Coordinated Home Care Program which does not have an agreement with the Claim Administrator or a Blue Cross Plan but has been certified as a home health agency in accordance with the guidelines established by Medicare.

  • Qualified medical provider means the same as that term is defined in Section 26-61a-102.

  • Health care provider or "provider" means:

  • Participating Retail Health Clinic means a Retail Health Clinic which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Federal Health Care Program means any “federal health care program” as defined in 42 U.S.C. § 1320a-7b(f), including Medicare, state Medicaid programs, state CHIP programs, the Veterans Administration, TRICARE and similar or successor programs with or for the benefit of any Governmental Authority, and in each case any third party payor administering such programs.

  • Non-Participating Clinical Professional Counselor means a Clinical Professional Counselor who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Health Care Operations shall have the meaning given to such term under the HIPAA 2 Privacy Rule in 45 CFR § 164.501.

  • Managed Care Program means the process that determines Medical Necessity and directs care to the most appropriate setting to provide quality care in a cost-effective manner, including Prior Authorization of certain services.

  • Care Plan means a licensee's written description of a resident's needs, preferences, and capabilities, including by whom, when, and how often care and services are to be provided.