What is external review?
External reviewis an independent review of certain final utilization management denials. New Jersey's Independent Health Care Appeals Program (IHCAP) is administered by the Department of Banking and Insurance (DOBI) and uses certified independent utilization review organizations (IUROs) under contract with the State.
The IURO is not affiliated with your insurance company. Applications are filed through Maximus Federal Services at njihcap.maximus.com.
General overview: Appeals roadmap. Complete New Jersey internal appeals first unless an urgent exception applies.
Note: This guide covers member utilization management external review. It is not the same as hospital–insurer claim payment arbitration for billed charges.
Who can use New Jersey review?
External review generally applies when:
- You have a fully insured New Jersey health plan subject to DOBI oversight
- The dispute involves medical necessity, appropriateness, health care setting, level of care, effectiveness, or experimental/investigational treatment
- You meet IHCAP eligibility after completing required internal appeal levels
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare and Medicare Advantage (federal Medicare appeals)
- Benefit exclusions that are not UM-based (e.g., “not a covered benefit” without a medical necessity review)
Deadlines & exhaustion
Four-month filing window
File with IHCAP within four months after you receive the carrier's final internal UM appeal determination (DOBI UM appeals Q&A; N.J.A.C. 11:24A-3.6). Follow any deadline in your denial letter.
Exhaust internal appeal first
Complete the carrier's internal UM appeal process before external review in most cases. Exceptions include:
- Carrier waives internal review in writing (DOBI Q&A)
- Carrier fails to issue a timely internal UM determination—you may proceed to the next stage (DOBI Q&A)
- Expedited external reviewmay run at the same time as expedited internal appeal when urgent (DOBI Q&A; N.J.A.C. 11:24-8.7)
How to file
- Complete internal appeal and obtain a final denial when required.
- Gather the denial letter, appeal correspondence, policy, and medical records.
- File online at njihcap.maximus.com or follow paper instructions on the DOBI IHCAP page.
- For expedited review, include physician certification that standard time frames would jeopardize life, health, or maximum function.
IHCAP help: 888-393-1062 or 609-777-9470 · Maximus: 888-866-6205 · Email: ihcap@dobi.nj.gov
Links hub: New Jersey external appeals links.
How long it takes
- Standard review: IURO decision within 45 calendar days of your request (DOBI — IHCAP)
- Expedited review: IURO decision within 48 hours when urgent
Is the decision binding?
For eligible disputes, the IURO decision is binding on the health carrier under the New Jersey Health Care Quality Act (N.J.S.A. 26:2S-11 et seq.). If the IURO reverses the denial, the carrier must provide coverage consistent with the decision.
Medicaid & Medicare
NJ FamilyCare: MCO appeal first, then DOBI IHCAP for UM disputes (often 60 days after MCO denial) or a DMAHS Medicaid fair hearing for eligibility and certain agency actions—not the same rules as commercial four-month IHCAP filing.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.