Amerigroup member handbook nj

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This member handbook tells you about your Amerigroup health plan and benefits. If you have questions about. We can help you in many languages. You can also get this handbook in large print, on audio tape or in Braille from Member Services.

If you do not have your Amerigroup ID card yet, you will get it soon. Please carry it with you at all times. Show it. The card tells them you are a member of Amerigroup.

You do not. Your ID card has the name and telephone number of your family doctor on it. Your effective enrollment date, or. The ID card tells your doctor that he or she should. Do not throw it away. Carry it with you in case you need those services. NJ FamilyCare members get.

This card is for. Below is an example of what your Amerigroup. The other side of this handbook is in Spanish. Show it to any doctor, dentist or hospital you visit. You do not have to show your ID card before you get emergency care. During this time, you will continue to receive benefits through Medicaid fee-for-service, or the HMO you are enrolled in, whichever applies.

This is known as the lock-in period. During the lock-in period, you can disenroll only for certain reasons. See page 56 for more about disenrollment. There are four different plans: A, B, C and D. The plan you are eligible for is based on your total family income and household size. Your family doctor will provide all of the basic health services you need. Your doctor can also send you to other specialist doctors, hospitals and special care facilities for special care, when needed.

You can have someone help you pick a family doctor or set up your first doctor visit. We will help you set up an appointment to get to know your doctor. Member Explanation of Benefits If y. If you choose to disenroll from Ame. Have a choice of specialists and ge. Suspicions of fraud and abuse can b.

The Complaint Resolution Analyst will investigate the grievance and you will get a written notification about the outcome within 30 days of receipt of the grievance. If you submit a written grievance by mail, a Complaint Resolution Analyst will try to contact you by telephone within 24 hours of receipt of the grievance to discuss and assist in resolving your grievance. The Complaint Resolution Analyst will document all the information discussed with you in our complaint tracking system.

An investigation will begin immediately. Written grievances are to be resolved as required by the urgency of the situation, but no later than 30 days after receipt. Once complete, you will receive a written notice with final outcome within 30 days of receipt of the grievance. This is called an appeal. An appeal can be oral or written. Appeals filed orally must be followed up with a written request.

All appeals must be submitted within 60 days of the date of the denial letter. Please follow the appeal process described below. This is called a Fair Hearing. You may request a Fair Hearing following the completion of an Internal Appeal.

However, the timeframe to request a Fair Hearing in writing is within days from the date of the notice of adverse decision following the Internal Appeal of a denial determination. Horizon NJ Health will review its decision about the services you asked for. This is an External Appeal. During the appeal process, you have the right to continue to get the Horizon NJ Health service in question until the end of the process if:?

Your appeal is filed in a timely fashion? The service was previously approved by Horizon NJ Health and the appeal involves the termination, suspension or reduction of that service? The service was ordered by an authorized provider? The appeal request is made on or before the final day of the previously approved authorization, or within 10 calendar days of the notification of adverse benefit determination, whichever is later In the event that Horizon NJ Health fails to meet its obligation to send the notification of adverse benefit determination at least 10 calendar days prior to the final day of the previously approved authorization, Horizon NJ Health shall automatically extend the authorization to a date 10 calendar days after the date on which the notification was sent.

You may ask for a copy of the benefit provision, guideline, protocol or other criterion on which the appeal decision was based. Horizon NJ Health will provide the medical records relating to the determination.

Internal Appeal Your Internal Appeal must be started no later than 60 days after the date of the denial letter sent to you. You or your doctor must:? Oral requests for an appeal must be followed up in writing, or? Fax your letter to the Appeals department at , or? Your doctor? That you want to appeal our decision 4. The reason you want to appeal 5. If the services are for urgent or emergency treatment Horizon NJ Health must get back to you with a decision within 30 calendar days.

If your appeal is about services for urgent or emergency treatment, we will tell you the results of your appeal within 72 hours three days? If we do not approve the services you are asking for in your appeal, Horizon NJ Health will send you a letter and explain why.

We will also tell you how to file an External Appeal. You have a right to appeal through Scion Dental? You must follow the following Internal Appeal Process. If you call first, you must follow-up your phone request by writing to Scion Dental at the address in 2 above. In your letter, you should include an explanation for the reason you are appealing our decision and then sign your request for an appeal.

You have 60 calendar days from the date on which the notification was sent to request an Internal Appeal. However, if you are now receiving these services, and you want these services to continue automatically during the appeal, you must either request an Internal Appeal on or before the final day of the previously approved authorization, or request an Internal Appeal within 10 calendar days from the date on which the notification was sent, whichever is later.

If you do not request your appeal within these timeframes, the services will not continue during the appeal. Scion Dental will decide your Internal Appeal within 30 calendar days of receipt of your appeal. If you or your treating provider believe this 30 calendar-day timeframe for deciding your appeal is too long and could harm your health, please call Scion Dental at TTY and ask for an expedited, or fast appeal. You may ask for an expedited, or fast appeal, if you are an inpatient in a facility, if the care you received was for an urgent or emergency health concern or if it is medically necessary and taking 30 calendar days to decide the appeal could seriously harm you in some way.

If you call to request an expedited, or fast appeal, you do not have to follow up your phone call with a written request.

Grievance and Appeal Procedures continued 52horizonNJhealth. Within 60 days of the date of Horizon NJ Health? Be sure to sign the form. Your signature allows the IURO to review your medical records and other medical information that may be needed for your appeal. The IURO will give you its decision within 45 days after it gets all the materials it needs to make a decision. You may present your information about your case directly to the Appeals Committee either in person or by telephone.

You may have someone come with you to the proceedings. If your appeal is about services for urgent or emergency treatment, you should call the DOBI at x, or call toll free at and ask that your appeal be reviewed within 48 hours two days?

You still must complete the form. This is known as a Fair Hearing. If you are eligible and want to ask for a Fair Hearing, as soon as you can, but no later than calendar days from the date of Horizon NJ Health?

That you want a Fair Hearing 4. The reason you want a Fair Hearing 5. If the services are for urgent or emergency treatment 6. Your telephone number 7. Include a copy of the Horizon NJ Health denial letter If you want to continue getting the benefits in question during the Fair Hearing process, you must request to do so in writing within 10 calendar days from the date of the notice of adverse decision following the Internal Appeal, or until the end of the prior approved authorization, whichever is later.

You must follow this timeframe, even though you have calendar days to request a Fair Hearing. If you request continued benefits and your appeal is denied, you may have to pay the cost of the services. At the hearing, someone outside of Horizon NJ Health and the State will review your request for services. This person is a judge from the Office of Administrative Law OAL , who will listen to you and others who speak for or with you at the hearing.

You have the right to be at the Fair Hearing or have a lawyer, friend or other person go with or for you. The OAL judge will give the State an opinion on your request and the State will then decide whether to accept or deny your request.