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State guide

New Jersey

Pick the kind of plan you have to see who to call first. New Jersey can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for New Jersey

New Jersey's external appeal, the Independent Health Care Appeals Program, is free and is filed directly with the state's contractor, Maximus. In the first half of 2026 the outside reviewers overturned or modified the insurer's denial in 57% of the cases they decided. New Jersey also has strong recent laws on prior authorization (2025) and step therapy (2026), and Medicaid (NJ FamilyCare) members can use the same external appeal on a shorter 60-day clock.

At a glance: independent review for plans New Jersey regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
New Jersey Department of Banking and Insurance (DOBI) · Consumer Hotline 1-800-446-7467; 609-292-7272; managed care complaints 1-888-393-1062
Independent review
A state process (Independent Health Care Appeals Program (IHCAP))
Deadline to request it
4 months after you receive the insurer's final internal appeal decision (60 days for NJ FamilyCare / Medicaid members)
Cost
none
Decision time
No more than 45 calendar days after the request is submitted (you are told within 5 business days whether the appeal was accepted); fast track: 48 hours

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Department says to check your insurance ID card to see whether your plan is self-funded. Self-funded plans that have opted in to New Jersey's out-of-network arbitration law show "NJ arbitration – YES" on the card. A self-funded plan is one where the employer pays claims itself, usually through a third party administrator, and state consumer protections generally do not apply to it.

Independent (external) review

Process
A state process. Run by New Jersey Department of Banking and Insurance; reviews are done by its contracted independent utilization review organization, Maximus Federal Services.
Where you file
regulator
How
File directly with the state's contractor, Maximus: online at https://njihcap.maximus.com, by fax to 585-425-5296, or by mail to Maximus Federal – NJ IHCAP, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. Include the insurer's written appeal decision(s), proof of coverage and relevant medical records (copies only). Questions: Maximus 888-866-6205, or the Department at 1-888-393-1062.
Which denials qualify
Utilization management denials: a service or payment denied, limited or ended because the insurer says it is not medically necessary, is experimental or investigational, or is cosmetic. Services that are simply not covered under the plan's terms are not eligible.
Appeal to the plan first?
Yes, you must complete the insurer's internal appeal (Stage 1, plus Stage 2 for group plans; individual plans and NJ FamilyCare need only Stage 1). Exceptions: the insurer missed its required timeframes, the insurer waived internal review, or you requested expedited internal and external review at the same time.
Published results
January 1 to June 30, 2026: reviewers decided 1,293 appeals; the insurer's denial was upheld 562 times (43%) and overturned or modified 731 times (57%). In the previous six months, 47% were overturned or modified. Source

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in New Jersey

Medicare and Medicaid in New Jersey

Medicare counseling
New Jersey State Health Insurance Assistance Program (SHIP) · 1-800-792-8820 (from outside New Jersey call (877) 222-3737) . Free help with Medicare appeals.
Medicaid agency
New Jersey Department of Human Services, Division of Medical Assistance and Health Services (NJ FamilyCare)
Fair hearing deadline
120 calendar days after you get the internal appeal denial letter from your health plan. Your notice states the deadline that applies to you.
Good to know
You must first file an internal appeal with your NJ FamilyCare health plan within 60 calendar days of the denial letter and wait for the result. You may also file an external appeal through the Independent Health Care Appeals Program within 60 days. To keep services you are already getting, ask for continuation of benefits within 10 calendar days of the date of the denial letter or before your current authorization ends, whichever is later. Not every NJ FamilyCare member is eligible for a Medicaid Fair Hearing; your plan can tell you.

Medicaid appeals page How Medicaid appeals work

State laws that can help

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Independent Health Care Appeals Program | New Jersey Department of Banking and Insurance
  2. Maximus Portal, New Jersey Independent Health Care Appeals Program
  3. Utilization Management Appeals and the Independent Health Care Appeals Program (questions and answers)
  4. Independent Health Care Appeals Reports
  5. Semi-Annual Legislative Report, Independent Health Care Appeals Program, January 1 to June 30, 2026
  6. Consumer Assistance, Inquiries and Complaints | New Jersey Department of Banking and Insurance
  7. Managed Care frequently asked questions and complaint form
  8. Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act information
  9. Bulletin No. 24-17: Ensuring Transparency in Prior Authorization Act
  10. P.L. 2025, c. 50 (step therapy)
  11. The NJ FamilyCare Health Plan Appeal Process Is Changing (Division of Medical Assistance and Health Services)
  12. New Jersey Consumer Assistance | Centers for Medicare & Medicaid Services
  13. Affordable Care Act: Working with States to Protect Consumers (state external review list) | Centers for Medicare & Medicaid Services
  14. New Jersey | State Health Insurance Assistance Programs
Not confirmed (4)
  • The independent review request form. this is the Maximus portal, where the Department says the appeal form can be downloaded; the address of the form file itself was not captured
  • Where to file for independent review. appeals go to the state's contractor (Maximus), not to the Department's own office; "regulator" is the closest allowed value
  • The Medicaid fair hearing page. the state document is a 2017 notice about the appeal rules; a current state web page on Medicaid fair hearings was not found, though a current health plan page repeats the same 120-day and 10-day deadlines
  • Free consumer help programs. no statewide nonprofit or legal aid program that clearly helps with insurance denials was confirmed

Sources last checked . Found a mistake? Report it.