Health insurance or Medicaid said no in New Jersey? Deadlines and free help

In New Jersey, your health plan is regulated by New Jersey Department of Banking and Insurance (DOBI), if it is a state-regulated plan.

New Jersey runs its own independent review of denials: Independent Health Care Appeals Program (IHCAP) external appeal. You generally have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

NJ FamilyCare

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Get Covered New Jersey) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in New Jersey?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months
Hearing deadline
30 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Get Covered New Jersey
90 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

Look at your ID card. If it says "Fully-Insured" or "Insured by" a company, and the plan was issued in New Jersey, the state appeal rules apply. If it says "Self-Insured", "Self-funded" or "Administered by", the plan is self-funded and federal rules apply instead.

Step 1: Appeal to your plan in New Jersey

What it is called: Internal appeal (Stage 1 and, for group plans, Stage 2) of a utilization management (UM) denial

New Jersey has two internal appeal levels for group (job-based) plans and one for individual plans. Stage 1 is an informal review with the plan's medical director or the doctor who made the denial. The plan must finish Stage 1 within 10 days, or within 72 hours for urgent or emergency care, a hospital admission, a continued stay, or emergency care before discharge. Stage 2 (group plans only) goes to a panel of health professionals who were not part of the denial. The plan must acknowledge it in writing within 10 business days and decide within 20 business days, or 72 hours in urgent cases. Denials that are not about medical judgment (administrative denials, such as an excluded service) go to the plan as a complaint, which it must answer within 30 days.

All the details →

Step 2: Outside review in New Jersey

Independent Health Care Appeals Program (IHCAP) external appeal

Deadline to ask: 4 months.

All the details →

Urgent care in New Jersey: faster decisions

Appeal to your plan

  • Your plan must decide an urgent appeal within 72 hours.

Outside review

Ask for an expedited appeal if it involves a hospital admission, a continued stay when you have not been discharged, or a condition where waiting 45 days could seriously jeopardize your life, health or ability to regain maximum function. You cannot have already received all of the services you are appealing. Expedited appeals are decided within 48 hours.

Law: DOBI Semi-Annual IHCAP Report (Jan.-June 2025); N.J.S.A. 26:2S-11, 26:2S-12 (as amended by P.L.2025, c.75)

Urgent: 48 hours

Marketplace

If you have an immediate need for health services and a delay could seriously jeopardize your life, health or ability to attain, maintain or regain maximum function, check the expedited appeal box on the form and explain why.

Law: N.J.S.A. 17B:27A-58; N.J.S.A. 45 CFR 155.520

Complaints about your plan in New Jersey

You can file a complaint with DOBI about any coverage problem, including billing, coverage denials, cost-sharing, ID cards, cancellations or customer service. File online, by phone (609-292-7272 or 1-800-446-7467), by fax (609-777-0508 or 609-292-2431) or by mail to NJDOBI, PO Box 471, Trenton, NJ 08625-0471. The Office of the Insurance Ombudsman is reached through the same lines.

sbs.naic.org

Medicaid (NJ FamilyCare (Medicaid)) denials in New Jersey

Who holds the hearing: New Jersey Office of Administrative Law (OAL) holds the hearing; the DMAHS Director issues the final agency decision.

Hearing deadline: 30 days

All the details →

Marketplace decisions in New Jersey

Marketplace

Get Covered New Jersey · 1-833-677-1010 (TTY 711)

Appeal deadline

90 days

The date on the eligibility determination notice you are appealing

How to appeal

Fill out the Marketplace Eligibility and Financial Assistance Appeal Request form, sign it and mail it with copies of supporting documents to Get Covered New Jersey, Attn: Appeals, PO Box 55898, Trenton, NJ 08638. You can appeal decisions about eligibility to enroll, financial help (APTC, cost-sharing reductions, New Jersey subsidy), special enrollment periods and catastrophic plans. Get Covered NJ may offer to resolve the appeal informally first.

Form

Marketplace Eligibility and Financial Assistance Appeal Request – Individual

Faster appeal

If you have an immediate need for health services and a delay could seriously jeopardize your life, health or ability to attain, maintain or regain maximum function, check the expedited appeal box on the form and explain why.

Law: N.J.S.A. 17B:27A-58; N.J.S.A. 45 CFR 155.520

Other rights in New Jersey

Who can deny a prior approval

Since January 1, 2025, any denial or limit on a requested service based on utilization management must be made by a physician working under a medical director licensed in New Jersey. The reviewing physician cannot be paid based on approval or denial rates.

Law: N.J.S.A. 17B:30-55.8 (P.L.2023, c.296, effective January 1, 2025)

How long a prior approval lasts

A prior approval for treatment of a chronic or long-term condition stays valid for 180 days. When you switch plans, the new plan must honor a prior approval from your old plan for at least the first 60 days of coverage once you or your provider send proof of it.

Law: N.J.S.A. 17B:30-55.7, 17B:30-55.10

Drug prior approval time limits

For prescription drug prior approval requests sent electronically, the plan must answer within 24 hours for urgent requests and 72 hours for non-urgent requests after it has all the information it needs.

Law: N.J.S.A. 17B:30-55.6

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in New Jersey and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in New Jersey

Good to know in New Jersey

  • New Jersey removed the fee for its state external appeal program in 2025.

    Law: P.L.2025, c.75, approved June 30, 2025, amending N.J.S.A. 26:2S-11

  • Group plans in New Jersey have two internal appeal levels (Stage 1 and Stage 2); individual plans and NJ FamilyCare plans have one.
  • NJ FamilyCare managed care members can use both the state external appeal (IHCAP, 60 days) and a Medicaid Fair Hearing (120 days) after the plan's appeal.

Changes in 2024–2026

January 1, 2025: the Ensuring Transparency in Prior Authorization Act took effect (physician review of denials, 180-day validity, 60-day honoring of a previous plan's approvals, 24/72-hour drug prior approval answers). June 30, 2025: P.L.2025, c.75 eliminated the IHCAP external appeal fee. July 1, 2026: NJ FamilyCare ended its unwinding-era fair hearing flexibilities: the 60-day filing period returned to 20 days from receipt, benefits no longer continue automatically while a hearing is pending, and the 90-day decision deadline applies again (DMAHS Medicaid Communication 26-06). A one-time late fair hearing request window (May 1 to June 30, 2026) for some people who got a CHIP grievance notice instead of a Medicaid fair hearing notice between June 26 and December 19, 2025 has closed.

Law: P.L.2023, c.296

Source: 30 days from the date on the notice; DHS Website Notice

Questions about appeals in New Jersey

How long do I have to appeal a health insurance denial in New Jersey?

You, or your provider with your consent, can appeal within 180 days of receiving the denial. For a group plan, a Stage 2 appeal must be filed within 180 days of the Stage 1 decision. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in New Jersey?

Independent Health Care Appeals Program (IHCAP) external appeal. Apply online at njihcap.maximus.com, or print the form there (or ask Maximus to mail or fax one) and send it by fax to 585-425-5296 or by mail to Maximus Federal – NJ IHCAP, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. Attach copies of the plan's Stage 1 and/or Stage 2 decisions, the plan's initial denial, the summary of coverage from your member handbook or certificate, your medical records and letters, and a signed consent and medical-records release (needed if your provider files for you).

Is outside review free in New Jersey?

There is no fee. A 2025 law removed the filing fee, and the plan (carrier) pays the cost of the review.

How long do I have to ask for a Medicaid fair hearing in New Jersey?

30 days. The date on the notice

Can I keep my Medicaid benefits while I appeal in New Jersey?

Since July 1, 2026, benefits do not continue automatically. When you ask for a fair hearing, you must choose (elect) to keep your benefits at the same level while the hearing is pending.

How do I appeal a Marketplace decision in New Jersey?

Fill out the Marketplace Eligibility and Financial Assistance Appeal Request form, sign it and mail it with copies of supporting documents to Get Covered New Jersey, Attn: Appeals, PO Box 55898, Trenton, NJ 08638. You can appeal decisions about eligibility to enroll, financial help (APTC, cost-sharing reductions, New Jersey subsidy), special enrollment periods and catastrophic plans.

Not about a denied claim?

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