How to Fill Out the New Jersey DOBI Member Consent Form

The New Jersey DOBI member consent form, formally titled “Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records,” is the document you sign to let a healthcare provider appeal an insurance denial on your behalf through the state’s Independent Health Care Appeals Program (IHCAP). You fill in your name, check the boxes that apply, add your insurance ID, indicate whether you are the patient or a personal representative, and sign and date it. The provider then submits it with the rest of your appeal package to Maximus Federal, the vendor that administers IHCAP for the Department of Banking and Insurance.¹

What You Are Actually Signing

The form does two things in one signature. It authorizes your provider to represent you in the utilization management appeal, and it authorizes that provider to release your medical records to the Independent Utilization Review Organization (IURO) assigned to your case, and, if you check the second box, to the Program for Independent Claims Payment Arbitration (PICPA).² Without this signed consent, a provider who tries to file on your behalf cannot proceed.

You can revoke your consent at any time during the process.³

Finish Your Internal Appeals First

Signing the consent form is pointless if your internal appeals with the carrier are not complete. IHCAP will reject the application during its preliminary screening if the internal process has not been finished or waived.¹ For most group plans, that means both Stage 1 and Stage 2. If you have an individual health benefits plan or Medicaid HMO coverage, only Stage 1 is required.

Hold on to every written denial letter the carrier sends you. Copies go into the appeal package along with the consent form.

Filling Out the Form, Field by Field

Download the form from the DOBI website or from the Maximus portal at njihcap.maximus.com. It is two pages, and both pages must be presented to you at the same time. A provider is not allowed to hand you page one and bring page two around later.²

Name. Print your full name in the blank at the top. If a personal representative is completing the form for you, that person prints their own name here instead.

Checkboxes. One checkbox authorizes your provider to represent you in the IHCAP appeal and share your medical information. A separate checkbox covers PICPA and Chapter 32 arbitration. Check only the boxes that apply to your situation. A provider cannot require you to check both.²

Insurance ID number. Copy this from your plan ID card. The instructions ask for it “if known at the time the form is completed,” so it is not strictly required, but filling it in prevents delays.²

Signatory status. Indicate whether you are the patient or a personal representative. This field is mandatory.

Personal representative contact information. If someone other than the patient is signing, that person fills in their own contact information in this section.

Signature and date. Sign and date the form. Leave the “representation by” fields blank. The provider fills in their own name there; that part is not yours to complete.

Protections to Know About Before You Sign

A few rules exist to keep this form from being used against you. No provider can require you to sign the consent form before you receive treatment or before you are admitted to a facility.⁴ Once you have signed, the provider must give you a photocopy of both pages for your records. And because you can revoke consent at any time, you are not locked in if you change your mind about having the provider represent you.

Submitting the Form With Your Appeal

The consent form does not go anywhere on its own. It is one piece of the IHCAP appeal application, which you or your provider submits to Maximus Federal by one of three methods:¹

Online at njihcap.maximus.com (fastest).
Fax to (585) 425-5296.
Mail to Maximus Federal – NJ IHCAP, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534.

Along with the signed consent form, the package needs to include:

Copies of your carrier’s Stage 1 and Stage 2 denial letters (just Stage 1 for individual plans and Medicaid HMO coverage).
The relevant portion of your member handbook, certificate of coverage, or other evidence of coverage.
Any medical records and correspondence you want the reviewer to see.

You have 60 days from the date of the carrier’s final internal denial to file.³ The clock runs from the date on the denial letter, not the date it arrived in your mailbox. Miss the 60 days and you lose the right to external review. There is no filing fee; the carrier pays the cost of the review.¹

When the Form and the IHCAP Do Not Apply

IHCAP covers disputes with health insurance carriers regulated by New Jersey, which is mostly fully insured plans sold in the individual and group markets. Self-funded employer plans governed by the federal Employee Retirement Income Security Act (ERISA) are outside New Jersey’s jurisdiction and are not required to participate. If your employer self-funds its health benefits instead of buying a policy from an insurance carrier, your external review rights come from the plan’s own procedures, usually through a contract with a private accredited review organization. Check your denial notice or call the member services number on your card to confirm which review process your plan uses.

For questions about eligibility or the consent form itself, the DOBI Office of Managed Care can be reached at 1-888-393-1062.⁵

1
New Jersey Department of Banking and Insurance. Independent Health Care Appeals Program
2
New Jersey Department of Banking and Insurance. Consent to Representation in Appeals of Utilization Management Determinations – Instructions
3
Justia. New Jersey Code 26:2S-11 – Independent Health Care Appeals Program
4
New Jersey Department of Banking and Insurance. Consent to Representation in Appeals of Utilization Management Determinations – Instructions
5
New Jersey Department of Banking and Insurance. Contact Information for Managed Care Filings