MedicaidAdministrativeMedium impact
Newsletter Vol. 34, No.04
New Jersey Medicaid·NJ·Prior Authorization
Effective date
May 1, 2024
We identified it
Jun 20, 2026
Summary
New Jersey updated its Fair Hearing appeal process for Permedion inpatient utilization review determinations. Hospitals now have the right to request a second-level Fair Hearing within 60 days of receiving an upheld adverse determination. All Fair Hearing requests must be submitted in writing to both DMAHS and Permedion and will undergo peer-to-peer physician review before submission to the Office of Administrative Law.
Action Required
By June 30, 2024: Billing and appeals team must establish a tracking system for all Permedion adverse determinations and their appeal deadlines. Within 60 days of receiving an upheld adverse determination letter, prepare and submit Fair Hearing requests in writing to DMAHS (P.O. Box 721, Trenton, NJ 08625 or fax 609-588-2435) AND Permedion (via email Permedion.NJUR@gainwelltechnologies.com or mail to Attn: NJ Appeals - Mailbox 519, P.O. Box 167728, Irving, TX 75016-7728). Include member name, date of birth, dates of service, Permedion ID number, and reason for appeal with each request. Note that peer-to-peer review with a Permedion physician will occur before OAL submission. Designate a staff member to manage this process and retain all documentation. Failure to submit within the 60-day window will forfeit appeal rights.