LYONS CONTINUED FROM PAGE 17
appeal for the independent external review after you have com-
pleted the internal appeal process. To file for an independent
external review, your external review request must be received
within four months of the date of the adverse benefit determi-
nation (if the date that is four months from that date is a Satur-
day, Sunday, or holiday, the deadline is the next business day).
Your request should be mailed or faxed to OptumRx.
Non-Urgent External Review
Once you have submitted your external review request, your
claim will be reviewed within five business days to determine
if it is eligible to be forwarded to an Independent Review Or-
ganization (IRO) and you will be notified within one business
day of the decision. If your request is eligible to be forwarded
to an IRO, your request will be randomly assigned to an IRO
and your appeal information will be compiled and sent to the
IRO within five business days. The IRO will notify you in writ-
ing that it has received the request for an external review and
if the IRO has determined your claim is eligible for review, the
letter will describe your right to submit additional information
within 10 business days for consideration to the IRO. Any ad-
ditional information you submit to the IRO will also be sent
to the claims administrator for reconsideration. The IRO will
review your claim within 45 calendar days and send you, the
plan, and OptumRx written notice of its decision. If the IRO has
determined that your claim does not involve medical judgment
or rescission, the IRO will notify you in writing that your claim
18
NEW JERSEY COPS
■ JUNE 2018
is ineligible for a full external review.
Urgent External Review
Once you have submitted your urgent external review re-
quest, your claim will be immediately reviewed to determine
if you are eligible for an urgent external review. An urgent sit-
uation is one where in the opinion of your attending provider,
the application of the time periods for making non-urgent care
determinations could seriously jeopardize your life or health or
your ability to regain maximum function or would subject you
to severe pain that cannot be adequately managed without the
care or treatment that is the subject of your claim. If you are
eligible for urgent processing, your claim will be immediately
reviewed to determine if your request is eligible to be forwarded
to an IRO, and you will be notified of the decision. If your re-
quest is eligible to be forwarded to an IRO, your request will be
randomly assigned to an IRO and your appeal information will
be compiled and sent to the IRO. The IRO will review your claim
within 72 hours and send you, the plan, and OptumRx written
notice of its decision.
Should you not be satisfied at any of these levels, you can
send an appeal to the State Health Benefits Commission, P.O.
Box 299, Trenton, NJ 08625-0299.
Be mindful that in order to win the appeal process, you must
be pursuing a drug that is being prescribed within the FDA
regulations and the mandatory generic or formulary. Where
there is not a medical necessity, it will not be approved. d
*Italicized print is from the Prescription Drug Plans Member
Guidebook.