Maximus C

[Henrietta Naughton]

This application for arbitration can be submitted by a health care provider, by the carrier (which, for purposes of this process includes the SHBP, the SEHBP, a MEWA, and any other payor providing a self-funded health benefits plan that opts into arbitration), or by a person covered by a self-funded health benefits plan in New Jersey that did not opt to participate in arbitration. However, a health benefits plan does not include coverage through Medicare or Medicaid.

If a health care provider needs to provide medical records to support a claim in arbitration, the health care provider must submit a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims. A covered person does not need to submit this form. The form is available at .

The application and arbitration process is composed of two parts, and there is a separate fee for each part of the process. The Initial Review determines whether your request qualifies for actual arbitration based on the information submitted. If the request qualifies, then the matter will go to arbitration for a decision on the case. However, to complete your application, you must remit payment for the Initial Review fee.

Upon filing the OON arbitration request here on this site, you will be prompted to submit payment electronically (convenience fee applies to electronic payments) or you may send two checks (or money orders) made payable to Maximus at the address below. The separate checks should be made for amounts consistent with the following:

In some cases, Maximus may need to request additional information from the Initiating Party, the Responding Party, or both. Maximus will make such requests to the appropriate Party in writing, and the Party will have ten (10) calendar days to respond with the requested information in writing. The Parties will have to submit the requested information via the portal.

Individuals seeking arbitration covered by a self-funded plan that did not opt in to C.32 OON Arbitration must submit an application directly to Maximus instead of completing the online application. Refer to Maximus contact information above to submit application and supporting documentation. The C.32 OON application is available at the bottom of this page.

If dissatisfied with a claims determination, but the situation does not meet the requirements for a Chapter 32 Independent Arbitration, there are other processes available for health care providers or consumers to use. See _insurance/managedcare/index.htm .

If you have any problems completing your application or you have questions regarding the arbitration process and other administrative matters, please contact Maximus via email at njarbi...@maximus.com. Please note that Maximus will not accept verbal arguments for inclusion in the case record.

- If the claims appeals was completed, or should have been completed, on or after August 1, 2007, then the application for arbitration must be completed and fees submitted within 90 days following the date the claims appeal was completed, or should have been completed by the payer, and Maximus will render a decision within 30 calendar days following receipt of application, documentation and fees.

Through this site, health care providers and carriers may submit an Application for Arbitration online, and attach supporting documentation if the information is in an electronic format, including scanned documents. To complete an application, the initiating party must first Register by clicking here . (After initial registration, the user will receive an email with login details within 48 business hours. You may not login to create cases until you receive your login details from Maximus.)

- All information related to your internal claims appeal, including a copy of the Health Care Provider Application to Appeal a Claims Determination, and the payer's decision, if any.

- All relevant medical records and billing records (HCFA 1500, UB92s).

- All relevant correspondence between the health care provider and payer.

- Although not required, a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims (Consent) should be submitted if the party requesting arbitration wants medical records reviewed by the arbitrator.*

* While a (Consent) is not required for the PICPA process, a missing or incomplete member consent may impact the information available to the arbitrator from the medical record which, in turn, may affect the arbitrator's decision. The Consent form is available on-line at the Departments website at www.state.nj.us/dobi/chap352/352consentform.doc

Upon filing the PICPA arbitration request here on this site, you will be prompted to submit payment electronically (convenience fee applies to electronic payments) or you may send two checks (or money orders) made payable to Maximus at the address below. The separate checks should be made for amounts consistent with the following:

Alert: Your case may be disaggregated. Maximus is permitted under the PICPA process to disaggregate cases when appropriate. Cases involving multiple lines of code and more than $2,000 may be disaggregated. You will be notified if your case is disaggregated. Please be aware that additional initial review fees and arbitration fees will be required if your case is disaggregated.

In some cases, Maximus may need to request additional information from the party initiating arbitration, the responding party, or both. Maximus will make such requests to the appropriate party in writing, and the party will have ten days to respond with the requested information in writing. Health care providers and Payers will have to submit the requested information via the portal.

Reviews will be based solely on the submitted documentation. Reviews will be performed by independent and impartial health claims professionals with at least five years of claims processing experience. Maximus will forward the written results of the Arbitration to the initiating party, responding party, and the New Jersey Department of Banking and Insurance within 30 calendar days following receipt of the documentation necessary for making a decision.

The Centers for Medicare and Medicaid Services (CMS), selected Maximus as the Part A and DME Qualified Independent Contractor (QIC) for second level independent external reviews of Medicare fee for service healthcare denials and as the national Independent Review Entity for external reviews of Medicare managed care denials.

Maximus offers a 24-hour secure, CMS compliant web portal for electronic submission of appeal requests. Many Provider organizations and health plans are currently using the QIC Appeals Portal, and Providers/Suppliers or plans who are interested can begin using it immediately.

Since 1975, Maximus has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs. Maximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability, and efficiency of government-sponsored programs. With more than 35,000 employees worldwide, Maximus is a proud partner to government agencies in the United States, Australia, Canada, Italy, Saudi Arabia, Singapore, South Korea, Sweden, and the United Kingdom. For more information, visit maximus.com.

Maximus is a group of experts on appeals. Medicare hired Maximus to look at denied appeals and decide if the health plan made the right decision and to perform reconsiderations of appealed Part A and DME redeterminations made by a Medicare Administrative Contractor. Maximus works for Medicare. Maximus does not work for the Medicare health plans. Our job is to conduct fair and independent reviews.

Our full-time employees include physicians, attorneys, nurses, therapists, public health experts, and certified coders. We are also supported by a large and distinguished panel of physicians and practitioner consultants in every medical specialty area.

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