New Jersey Administrative Code

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Brand name drug" means a prescription drug whose manufacture and sale is controlled by a single company as a result of a patent or simil…

(a) A network deductible is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA pol…

(a) Network coinsurance is permitted in a contract issued by a health maintenance organization that provides out-of-network benefits only for emergency and urgent care, in a POS contract issued by a health maintenance organization or health service corporation, and in an SCA poli…

(a) Network copayments in health benefit plans and stand-alone prescription drug plans may not exceed the following amounts: 1. Preventive services, $ 30.00; 2. Primary care provider office visit, $ 50.00; 3. Specialist physician office visit, $ 75.00; 4. Emergency room visit, $ …

(a) The following shall apply to individual network, family network and individual out-of-network out-of-pocket limits: 1. Carriers shall track the accumulation of copayment, deductible and coinsurance payments to identify when the out-of-pocket limit has been satisfied, and shal…

Notes N.J. Admin. Code § 11:22-5.7 Reserved by 51 N.J.R. 501(b), effective 4/15/2019

(a) POS contracts issued by health maintenance organizations and health service corporations, and SCA policies issued by insurance companies, shall provide coverage for covered services and supplies regardless of whether rendered by a network or an out-of-network provider, with t…

(a) Health benefit plans and stand-alone prescription drug plans that provide benefits for prescription drugs listed on a formulary may provide higher benefits for formulary drugs than for nonformulary drugs, provided: 1. The benefit for all tiers of formulary and nonformulary dr…

A health benefit plan or stand-alone prescription drug plan must provide prescription drug benefits for the termination of pregnancy consistent with N.J.S.A. 26:2S-39 and N.J.A.C. 11:22-5.9. Notes N.J. Admin. Code § 11:22-5.9A Adopted by 55 N.J.R. 2007(b), effective 9/18/2023…

(a) This chapter specifies standards for war and other exclusions and preauthorization requirements in health benefit plans. (b) This chapter applies to any insurance company, health service corporation, medical service corporation, hospital service corporation and health mainten…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Act of war" means any act peculiar to military, naval or air operations in time of war. "Carrier" means an insurance company, health se…

(a) The Department shall permit war risk exclusions in health benefit plans only if they consist of military exclusions, noncombatant exclusions and/or civilian exclusions. Military, noncombatant and civilian exclusions shall be no more restrictive than the following: 1. Military…

Preauthorization provisions may be included in health benefit plans only upon compliance with the requirements of N.J.A.C. 11:4-42.8, except for N.J.A.C. 11:4-42.8(a)5. Notes N.J. Admin. Code § 11:22-6.4

Forms filed before February 17, 2004 with noncomplying war exclusions and/or preauthorization provisions shall be administered in accordance with the standards of N.J.A.C. 11:22-6.3 and 6.4 and shall be deemed withdrawn as of January 1, 2005. Notes N.J. Admin. Code § 11:22-6.5…

(a) The purpose of this subchapter is to implement N.J.S.A. 52:17B-196 et seq., which provides for joint negotiations regarding non fee-related matters, fees and fee-related matters by physicians and dentists with carriers. This subchapter establishes standards and procedures for…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health ma…

(a) Every carrier shall report to the Department quarterly the number of covered persons enrolled in a dental plan or health benefits plan during that quarter in a format set forth in this subchapter as Appendix A, incorporated herein by reference. Instructions for completing thi…

(a) The purpose of this subchapter is to establish standards and criteria regarding information contained on health insurance identification cards issued by carriers authorized to issue health benefit plans in this State. (b) This subchapter shall apply to all insurance companies…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Card," "health insurance identification card" or "identification card" means a card issued by a health benefit plan to a subscriber or …

(a) Each carrier or third party administrator shall issue, or cause to be issued, an identification card to the primary insured covered by a health benefit plan. Additional cards may be issued to other persons included under the primary insured's coverage. The carrier or third pa…

(a) Beginning on the operative date of this subchapter, health insurance identification cards shall be provided according to the following schedule: 1. A carrier or third party administrator shall provide each primary insured a new identification card within 30 days of a health b…

(a) Every carrier or third party administrator issuing a card pursuant to this subchapter shall make an informational filing of the form of the card with the Department. The filing shall contain the form of the card with all required information specific to the fictitious insured…

This subchapter shall become operative on July 1, 2010. Notes N.J. Admin. Code § 11:22-8.6

(a) The purpose of this subchapter is to implement P.L. 2009, c. 113 by establishing a process whereby, if requested by such a provider, a health insurance carrier shall reimburse a New Jersey licensed obstetrical provider in installments for maternity services rendered by the pr…

The following words and terms, when used in this subchapter, shall have the meanings as set forth below unless the context clearly indicates otherwise: "CPT" means the American Medical Association's Current Procedural Terminology (CPT) maintained by the American Medical Associati…

(a) Obstetrical providers may elect to be reimbursed for maternity services rendered to a covered person on either a global basis (one payment for all services rendered during the term of a covered person's pregnancy for antepartum care, delivery and postpartum care) or on an ins…

(a) For providers electing to be reimbursed for maternity services on a global basis, carriers shall accept billings under the CPT codes most current to the date of billing for services as published by the AMA for global routine maternity care. The global routine maternity care C…

(a) For providers electing to be reimbursed for maternity services on an installment basis, carriers shall remit at least three equal installment payments during the term of the covered person's pregnancy as follows: 1. Following the 12th week of pregnancy; 2. Following the 28th …

This subchapter shall apply to pregnancies beginning on or after January 5, 2012. Notes N.J. Admin. Code § 11:22-9.6

(a) This chapter sets forth the licensing and registration requirements of third party administrators of health benefits plans and the certification requirement of third party billing services in accordance with the provisions of N.J.S.A. 17B:27B-1 et seq. (b) This chapter applie…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Act" means N.J.S.A. 17B:27B-1 et seq., an act concerning third party administrators of health benefits plans and third party billing servi…

(a) No person shall act as, offer to act as, or hold himself or herself out to be, a third party administrator in this State unless licensed or registered by the Commissioner as set forth in N.J.A.C. 11:23-2.2. (b) Every third party administrator that is either not licensed in Ne…

(a) All third party administrators subject to licensure or registration shall obtain licensure or registration prior to operating in this State. (b) Application for licensure or registration shall be made on a form prescribed by the Commissioner which can be found on the Departme…

(a) The Commissioner may issue a license to an applicant or approve an application for registration as a third party administrator if he or she finds that the applicant meets the following standards:1. All of the materials required by the Act, this chapter or by the Commissioner …

(a) The time period for the Department's review of an application shall commence the day the application is received. (b) The Department shall advise the applicant if the application is incomplete not later than 60 days after receipt of the application. (c) The application shall …

The Commissioner may deny an application for licensure or registration as a third party administrator if he or she finds that any of the standards established by the Act or these rules have not been met or for any other reasonable grounds. If the application for licensure or regi…

In addition to the application review, an organizational investigation or examination may be performed before or after an applicant is licensed or registered as a third party administrator. Such investigation or examination shall consist of a general survey of the third party adm…

(a) A third party administrator shall not conduct any business with a benefits payer in the absence of a written agreement between the administrator and the benefits payer. This subsection shall not apply to a third party administrator registered in accordance with N.J.A.C. 11:23…

(a) The Commissioner shall have access to all books and records of a third party administrator for the purposes of examination, audit and inspection, the reasonable expense of which shall be paid to the Department by the third party administrator. Any trade secrets, proprietary i…

If a third party administrator adjudicates claims under a health benefits plan, the commissions, fees or charges that the benefits payer pays the administrator shall not be based solely on the number or amount of claims denied or adjusted downward by the administrator. This provi…

(a) A third party administrator shall be deemed to act in a fiduciary capacity on behalf of the benefits payer in the receipt and transmittal of the funds of a benefits payer, and shall have all responsibility attendant to a fiduciary as established by law. (b) An administrator s…

(a) All funds remitted to an administrator by a benefits payer licensed or authorized to do business in this State shall be held by the third party administrator in a separate account maintained in the name of the benefits payer, or in a separate account maintained jointly in the…

Any policies, certificates, booklets, termination notices or other written communications delivered by the benefits payer to the third party administrator for delivery to enrollees shall be delivered by the administrator promptly, in accordance with the instructions of the benefi…

A third party administrator shall immediately notify the Commissioner in writing of any material change in its ownership, control, or other fact or circumstance affecting its qualifications for a licensure or registration, as applicable, including, but not limited to, a change in…

(a) A third party administrator shall file with the Commissioner on or before June 1 of each year an annual report for the preceding calendar year that shall consist of an audited and an unaudited part. The unaudited part shall contain the complete names and addresses of all bene…

No third party administrator shall contract with or on behalf of a self-funded multiple employer welfare arrangement (MEWA) which is not duly registered with the Department pursuant to N.J.S.A. 17B:27C-1 et seq. It shall be the responsibility of the third party administrator to v…

(a) The Commissioner may suspend or revoke a license or registration issued pursuant to the Act if he or she finds that the third party administrator: 1. Is in an unsound financial condition; 2. Is using methods or practices in the conduct of its business that render its further …

(a) The Commissioner may, without advance notice or hearing, enter an order temporarily suspending the license or registration of a third party administrator if he or she finds that one or more of the following circumstances exist: 1. The administrator is insolvent or impaired; 2…

The Commissioner may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $ 250.00 nor more than $ 5,000 for each day that a third party administrator is in violation of the Act. A penalty imposed by the Commissioner pursuant to this section …

(a) No person shall act as, offer to act as or hold himself or herself out to be a third party billing service in this State unless certified by the Commissioner in accordance with the Act. (b) All third party billing services shall obtain certification prior to operating in this…