New Jersey Administrative Code

(a) All data or information filed with the Department pursuant to N.J.A.C. 11:21-9.3(a) are public records and may be disclosed in accordance with N.J.S.A. 47:1A-1 et seq., except that actuarial memoranda which contain confidential and proprietary information pursuant to N.J.A.C.…

Failure to comply with the provisions of this subchapter may result in the imposition of fines or other penalties provided by N.J.S.A. 17B:27A-43. Notes N.J. Admin. Code § 11:21-9.8 Recodified from N.J.A.C. 11:21-9.6 by R.2002 d.342, effective 11/4/2002. See: 34 New Jersey Regist…

(a) This chapter implements N.J.S.A. 17B:30-26 through 34, which sets standards for the payment of claims relating to health benefit plans and dental plans. (b) This chapter applies to any insurance company, health service corporation, medical service corporation, hospital servic…

(a) Every health carrier or its agent shall establish an internal appeals mechanism to resolve payment disputes between health carriers or their agents and health care providers, but not including appeals related to medical necessity made pursuant to N.J.A.C. 11:24-8.5, 8.6, and …

(a) Every dental plan organization and dental service corporation shall establish an internal appeals mechanism to resolve disputes between dental carriers or their agents and participating health care providers relating to payment of claims for services or supplies covered by a …

(a) Every dental plan organization and dental service corporation shall offer an independent, external alternative payment dispute resolution (ADR) mechanism to participating health care providers to review adverse decisions of its internal appeals process. 1. The ADR mechanism s…

(a) Any dispute regarding the determination of an internal appeal conducted pursuant to a health carrier's or its agent's internal appeal mechanism established pursuant to P.L. 2005, c. 352, and described at N.J.A.C. 11:22-1.10, may be referred to arbitration, except for the foll…

(a) A carrier or ODS shall report to the Department on a quarterly and annual basis on the timeliness of claims payments and on the reasons for denial and late payment of claims in a format set forth by bulletin or similar means and/or on the Department's website. Due dates for t…

(a) Upon review of the reports required by N.J.A.C. 11:22-1.14, the Commissioner may require that the carrier, ODS, or the agent of a carrier or ODS, at its own expense: 1. Implement a plan of remedial action; and/or 2. Have the claims processing procedures of the carrier or its …

(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan. (…

(a) The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "ADR" or "alternative dispute resolution" means any procedure, other than litigation, used in the conciliatory resolution of a dispute,…

(a) A carrier or its agent shall acknowledge receipt of all claims. The acknowledgement shall include the date the carrier or its agent received the claim. 1. If a claim is submitted by electronic means, the claim shall be acknowledged electronically no later than two working day…

(a) A health carrier or its agent shall provide in a clear and conspicuous manner through a publicly accessible internet website information concerning the submission and processing of claims including, but not limited to, where applicable: 1. A list of the material, documents, o…

(a) A carrier and its agent shall remit payment of clean claims pursuant to the following time frames: 1. Thirty calendar days after receipt of the claim where the claim is submitted by electronic means or the time established for the Federal Medicare program by 42 U.S.C. § 1395u…

(a) A carrier or its agent shall either deny or dispute a claim, in full or in part, that has not been processed according to N.J.A.C. 11:22-1.5. If only a portion of a claim is disputed or denied, the carrier or its agent shall remit payment for the uncontested portion in accord…

(a) Payment of a capitation payment to a health care provider shall be deemed to be overdue if not remitted to the provider on the fifth business day following the due date of the payment in the contract, if: 1. The health care provider is not in violation of the terms of the con…

(a) No carrier or its agent shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances: 1. In judicial or quasi-judicial proceedings, including arbitration; 2. In governmental administrative proceedings; 3.…

(a) No health care provider shall request reimbursement from a health carrier or its agent or from a covered person later than 18 months from the date the first payment on the claim was made unless the claim is the subject of an internal appeal pursuant to N.J.A.C. 11:22-1.10 or …

This subchapter applies to health benefits plans that are delivered, issued, executed or renewed in this State on or after (the effective date of this subchapter). Notes N.J. Admin. Code § 11:22-2.1

The following words and terms, when used in this subchapter, shall have the meanings as set forth below, unless the context clearly indicates otherwise: "Act" means the Health Wellness Promotion Act, P.L. 1993, c.327, as amended by P.L. 1999, c. 339. "Carrier" means an insurance …

(a) Every health benefits plan issued by a carrier shall provide benefits for a health wellness promotion program, which shall include, at a minimum, the following tests and services:1. For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood p…

The Department and the Department of Health and Senior Services for HMO's, in consultation with the Department of Treasury, shall calculate the maximum dollar amount of services or benefits to be provided no later than July 1 annually, and shall publish the results of the calcula…

(a) Pursuant to N.J.S.A. 17B:30-23 et seq., P.L. 1999, c. 154 (the Health Information Electronic Data Interchange Technology Act ("HINT" or "the Act")), the purpose of this subchapter is to establish timetables for the introduction and implementation of systems for the electronic…

Notes N.J. Admin. Code § 11:22-3.10 Recodified to N.J.A.C. 11:22-3.8 by R.2011 d.256, effective 10/17/2011. See: 43 N.J.R. 1236(a), 43 N.J.R. 2668(b). Section was "Fraud prevention and detection".

Notes N.J. Admin. Code § 11:22-3.11 Recodified to N.J.A.C. 11:22-3.9 by R.2011 d.256, effective 10/17/2011. See: 43 N.J.R. 1236(a), 43 N.J.R. 2668(b). Section was "Penalties".

The following words, phrases and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Agent" means any entity, including a subsidiary of a carrier, or an organized delivery system as defined by N.J.S.A. 17:48H-1 …

(a) 45 C.F.R. 162.1101, Subpart K, the Health Care Claims or Equivalent Encounter Information Standard, and 45 CFR 162.1501, Subpart O, the Enrollment and Disenrollment in a Health Plan Standard, are adopted by the Department, in consultation with the Department of Health and Sen…

(a) On or after October 1, 2002, all payers shall require that all providers file all claims for payment unless the patient, at his or her option, files the claim directly. (b) Where a claim is being filed by the health care provider on behalf of the patient without an assignment…

(a) In accordance with N.J.A.C. 11:22-1.3, payers receiving an electronically filed claim shall individually acknowledge receipt of each claim by responding with a 277 Transactions, ANSI ASC X12.317, Version 003070, Release 7, Sub-release O, October 1996, Electronic Health Care C…

(a) When computing the number of days for purposes of acknowledging an electronic claim and/or any other health care transactions required by this subchapter, the following shall apply: 1. When the provider chooses to use a clearinghouse for the transmission of claims to a payer,…

All information and materials coming into the possession of health benefits payers, health care providers and their agents and vendors for the administration of the health care transactions described in this subchapter are subject to and shall comply with practices and requiremen…

(a) All payers shall deploy as part of any system for the electronic receipt and transmission of claims an anti-fraud program, resident system and/or software that is approved by the Department's Division of Anti-Fraud Compliance. (b) The anti-fraud system described in (a) above …

Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including suspension or revocation of the payer's authority to do business in the State of New Jersey. Notes N.J. Admin. Code § 11:22-3.9 Recodified from N.J.A.C. 11:22-3.11 by …

(a) This subchapter sets forth the filing and requirements for an entity to be licensed as an organized delivery system pursuant to N.J.S.A. 17:48H-1 et seq. (b) This subchapter applies to any entity seeking to become licensed as an organized delivery system pursuant to N.J.S.A. …

Regardless of the state in which it is incorporated, pursuant to N.J.S.A. 17:48H-16 and 26 a licensed organized delivery system shall be treated as a domestic insurer subject to N.J.S.A. 17:27A-1 et seq. and 17B:32-31 et seq. Notes N.J. Admin. Code § 11:22-4.10 New Rule, R.2008 d…

(a) The Commissioner may suspend or revoke the license issued to an organized delivery system upon a finding that: 1. The licensed organized delivery system is operating in contravention of its basic organizational documents; 2. The licensed organized delivery system is unable to…

In connection with the plan for insolvency required as part of an application for licensure, a licensed organized delivery system shall maintain insurance to cover the expenses to be paid for continued benefits following a determination of insolvency, or make other arrangements a…

(a) Any data or information relating to the diagnosis, treatment or health of an enrollee, prospective enrollee or contract holder obtained by a licensed organized delivery system from the carrier, contract holder, enrollee, prospective enrollee or any provider shall be confident…

Failure to comply with the provisions of this subchapter shall result in the imposition of penalties as provided in N.J.S.A. 17:48H-22, 17:48H-29, 17B:30-17, 17:27A-1 et seq., 26:2S-1 et seq., 17B:30-23 et seq. and 17B:30-26 et seq. Notes N.J. Admin. Code § 11:22-4.14 Amended by …

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under c…

(a) An organized delivery system that receives compensation on a basis that entails the assumption of financial risk shall submit an application for licensure to the Commissioner. 1. This subchapter shall apply to any contract issued and/or renewed on or after October 21, 2002. (…

(a) An application for a license to operate an organized delivery system shall be filed with the Commissioner, and shall contain a completed application, containing the information and in the format set forth in Exhibit A in the Appendix to this subchapter, incorporated herein by…

(a) The Commissioner shall review an application for licensure and notify the applicant of any deficiencies contained therein within 60 days of receipt. An applicant shall address any deficiencies in its application within 60 days of notice thereof. (b) Upon receipt and review of…

(a) A licensed organized delivery system shall not materially modify any matter or document furnished pursuant to N.J.A.C. 11:22-4.4 unless the system files with the Commissioner a notice of the change or modification, together with any additional information to explain the chang…

(a) The Commissioner may conduct an examination of a licensed organized delivery system as often as he or she deems necessary in order to protect the interests of providers, contract holders, enrollees, and the residents of this State, but not less frequently than once every five…

(a) Except as provided in (i) below, a licensed organized delivery system shall, at all times, have and maintain a minimum net worth, determined on a statutory accounting basis, in an amount equal to the greater of: 1. Two percent of the annual compensation received by the organi…

(a) A licensed organized delivery system shall file an annual report for the segregated account established pursuant to N.J.A.C. 11:22-4.8(b) with the Commissioner, on or before March 1 of each year, for the immediately preceding calendar year, completed as prescribed by the Nati…

(a) This subchapter establishes minimum standards for health benefit plans, prescription drug plans and dental plans. (b) This subchapter applies to all insurance companies, health service corporations, medical service corporations, hospital service corporations, dental service c…

(a) The following standards apply to health benefit plans and stand-alone dental plans that provide benefits for dental services only when rendered by network providers, and plans that provide benefits for dental services rendered by both network and out-of-network providers:1. T…

Any form that was previously filed with and approved by the Commissioner, but does not meet the requirements of this subchapter, shall be deemed withdrawn as of September 8, 2010 and may not be made available for new issue or for renewal on or after that date. Notes N.J. Admin. C…