New Jersey Administrative Code

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 billing service is in violation of the Act. A penalty imposed by the Commissioner pursuant to this sectio…

(a) Application for certification shall be made to the Commissioner on a form provided by the Commissioner that can be found on the Department's website at www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm. (b) The following information shall accompany the applicati…

(a) In addition to the information otherwise required by the Act, these rules, or based upon the unique facts of particular cases, by the Commissioner, a third party billing service shall file with the Commissioner: 1. A description of the applicant's proposed method of marketing…

(a) The Commissioner may approve an application for certification as a third party billing service if he or she finds that the applicant meets the standards established by the Act, including, but not limited to, the following: 1. All of the information required by the Act, these …

(a) The Commissioner may deny an application for certification as a third party billing service 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. (b) If the application for certification is de…

(a) A third party billing service shall not conduct any business with a client in the absence of a written agreement between the billing service and the client. The agreement shall be retained as part of the official records of the third party billing service for the duration of …

(a) A third party billing service that accepts monies from benefits payers on behalf of a client shall be deemed to act in a fiduciary capacity on behalf of the client in the receipt and transmittal of funds and shall have all responsibility attendant to a fiduciary as establishe…

A third party billing service shall immediately notify the Commissioner of any material change in its ownership, control, or other fact or circumstance affecting its continuing qualification for Certification. Notes N.J. Admin. Code § 11:23-5.8

(a) The Commissioner may suspend or revoke a certification issued pursuant to the Act if he or she finds that the third party billing service: 1. Is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous o…

(a) The rules in this chapter were developed by the Commissioner of Health and Senior Services in collaboration with the Commissioner of Banking and Insurance and govern the establishment and operation of health maintenance organizations in New Jersey pursuant to the authority se…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Adverse benefit determination" means a denial, reduction or termination of, or a failure to make payment (in whole or in part) for, a bene…

(a) The HMO shall develop and implement a policy for the transfer of medical records of members whenever the following occur: 1. Change of physician or other provider; 2. Disenrollment of member from HMO; or 3. Other circumstances where requested by members or former members; (b)…

Any data or information pertaining to the diagnosis, treatment, or health of any member or applicant obtained from the member or from any provider by any HMO shall be held in confidence. The data or information shall not be disclosed to any person, except to the extent that it ma…

Any medical records directly maintained by the HMO shall be organized in a uniform format across all records subject to the requirements of applicable law. The HMO shall have policies governing the contents of medical records. Notes N.J. Admin. Code § 11:24-10.3

Members or their legally authorized representatives shall have a right to inspect and obtain a copy of their medical records maintained by the HMO. Charges for copies of medical records shall be based upon actual costs, not to exceed prevailing community rates for photocopying. N…

Medical records maintained by HMO's shall be protected against loss, destruction, or unauthorized use and retained for at least 10 years or until the member reaches age 23 years, whichever is longer. Notes N.J. Admin. Code § 11:24-10.5

(a) In order to obtain a certificate of authority, an HMO shall have a minimum net worth, determined on a SAP basis, of at least $ 1,500,000 in cash or cash equivalents, as adjusted annually by the CPI, together with such other guarantees and assets as the Commissioner may determ…

Except as approved by the Commissioner in accordance with N.J.S.A. 26:2J-5a(1) and (3), all investments of HMOs shall be subject to and in compliance with N.J.S.A. 17B:20-1 et seq. Notes N.J. Admin. Code § 11:24-11.2

(a) An HMO shall maintain at all times reserve liabilities in an amount sufficient to provide for: 1. All claims incurred, whether reported or unreported, which are unpaid and for which the HMO is or may become liable, including the expense of adjustment or settlement of those cl…

(a) In order to obtain a certificate of authority, every HMO shall deposit with the Commissioner no less than $ 300,000, adjusted annually by the CPI beginning on July 1, 1997 in accordance with N.J.A.C. 11:2-32, Custodial Deposits. (b) In order to maintain a certificate of autho…

(a) In order to obtain and maintain a certificate of authority, an HMO shall submit a plan to the Commissioner, which assures continuation of services and benefits to members when the HMO is declared by a court of competent jurisdiction to be insolvent and placed in rehabilitatio…

(a) Every HMO shall submit, no later than March 1, an annual report for the immediately preceding calendar year, completed as prescribed by the NAIC Annual Statement Instructions for Health Maintenance Organizations, and completed on a SAP basis, in accordance with the NAIC Accou…

(a) In conjunction with the submission of the New Jersey--Specific Annual Supplement made in accordance with N.J.A.C. 11:24-11.6(c), every HMO shall submit aggregate reports on compensation arrangements between the HMO and providers under contract with the HMO (directly or throug…

(a) Prior to issuing or amending any contracts for coverage, an HMO shall submit a certification, including an actuarial opinion certified by a member of the American Academy of Actuaries or an active fellow of the Society of Actuaries, for filing with the Commissioner demonstrat…

Notes N.J. Admin. Code § 11:24-11.9 Repealed by R.2002 d.265, effective 8/19/2002. See: 34 N.J.R. 885(a), 34 N.J.R. 3014(a). Section was "Subrogation and third party claims".

(a) An HMO shall cease new enrollment, except for addition of family members of current members, upon receipt of notice of the filing of a petition by the Commissioner for an order authorizing rehabilitation of the HMO pursuant to N.J.S.A. 17B:32-31 et seq., Life and Health Insur…

(a) The Commissioner may order carriers and other HMOs to offer the members of an insolvent HMO an opportunity to become insured or to enroll with the carriers and other HMOs, during no less than a 30-day open enrollment period to be determined by the Commissioner, except as (b) …

(a) Except as (e) below or N.J.A.C. 11:24-13.2 may apply, no HMO shall employ, directly or indirectly, any person to solicit, negotiate or bind contracts for the delivery to subscribers or members of health care services through an HMO, or to communicate with subscribers or membe…

(a) Notwithstanding N.J.A.C. 11:24-13.1, an HMO under contract with the Division of Medical Assistance and Health Services of the New Jersey Department of Human Services to enroll Medicaid recipients shall register its marketing representatives employed solely for the purpose of …

Except to the extent that HMOs shall be specifically exempted by reference by a provision of an applicable statute or rule, HMOs, producers and Medicaid marketing representatives shall comply with statutes and rules regulating the marketing, advertising, solicitation and sale of …

(a) HMOs shall make the following disclosure statements, as applicable, in all applications for enrollment and member handbooks: 1. Every HMO shall make the following disclosure: "[Different] providers in our network have agreed to be paid [in different ways by us. Your provider …

(a) HMOs shall be subject to all of the provisions of the Trade Practice Act, N.J.S.A. 17B:30-1 et seq., any amendments thereto, and all rules promulgated thereunder, except to the extent that HMOs have been specifically excluded by reference from a provision of the applicable st…

Every producer or Medicaid marketing representative found to be in violation of this subchapter shall be subject to penalties and fines (per contract) in accordance with N.J.A.C. 11:17D, including suspension or revocation, in whole or in part, of his or her producer license or re…

(a) The purpose of this subchapter is to set forth the standards by which HMOs shall offer and deliver a contract for a point of service product in New Jersey. (b) This subchapter applies to all HMOs authorized to transact business in this State for the purposes of providing heal…

(a) An HMO shall offer a point of service product in this State that allows a member to receive covered services from an out-of-network health care professional without obtaining a referral or prior authorization from the HMO, except if: 1. Its only members are Medicaid recipient…

(a) Except as set forth in (b) below, an HMO shall not enter into any arrangement for the provision of out-of-network covered services to any subscriber or member that is not in compliance with this subchapter. (b) An HMO providing out-of-network covered services under an arrange…

(a) An HMO may offer a POS contract with or without a gatekeeper system for out-of-network covered services, except that any POS contract offered without a gatekeeper system for out-of-network covered services shall meet the following: 1. The deductible for the out-of-network cov…

(a) The reinsurance-type contract shall cover the entire cost of the out-of-network covered services, and shall not provide for any deductible, coinsurance, copayment, or other type of mechanism by which any portion of the out-of-network covered services become self-funded by the…

(a) The master policy form, certificate form, and any other form that becomes a part of the group health contract, as applicable, shall be submitted by the carrier electronically, pursuant to N.J.A.C. 11:4-40.4. (b) The master policy form shall comply with all applicable insuranc…

(a) No HMO shall enter into a dual contracting arrangement until both the HMO contract forms and rates thereof and the indemnity policy forms and rates thereof, as applicable, have been submitted to the Department for filing, each with unique identifying numbers for the dual cont…

Notes N.J. Admin. Code § 11:24-14.8 Repealed by R.2000 d.183, effective 5/1/2000. See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a). Section was "Network variations".

Notes N.J. Admin. Code § 11:24-14.9 Repealed by R.2000 d.183, effective 5/1/2000. See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a). Section was "Penalties".

(a) No person shall assume financial risk, in whole or in part, for the cost or provision of, or arrangements for, one or more health services to others unless the person is: 1. An authorized payor as defined at N.J.A.C. 11:24-1.2; 2. A provider actually performing the health ser…

(a) Both primary contractor and secondary contractor agreements shall be consistent with laws regarding confidentiality of information and with professional licensing standards, including, but not limited to, N.J.S.A. 45:14B-31 et seq., and shall comply with the standards of (b) …

(a) The form(s) of the provider agreement(s), and any amendments thereto, shall be submitted to the Department at the address specified at N.J.A.C. 11:24-11.6(i), for prior approval by the Department. (b) Provider agreements in effect upon May 1, 2000 shall be deemed withdrawn on…

Every person acting as a secondary contractor in violation of this subchapter shall be subject to penalty and fine by the Department under the insurance laws of this state as an unauthorized insurer in accordance with N.J.S.A. 17:51-1 et seq., or 17B:33-1 et seq., as may be appro…

(a) This subchapter shall apply to all HMO health benefits plans that are not standard health benefits plans promulgated by the Small Employer Health Benefits Program Board of Directors and which are not otherwise subject to the Small Employer Health Benefits Program Act, N.J.S.A…

(a) The HMO shall provide a written contract to the contractholder and an evidence of coverage to each subscriber, which evidence of coverage may be incorporated into the member handbook required pursuant to N.J.A.C. 11:24-9.1. 1. The contract, evidence of coverage and member han…

(a) Every plan document shall contain the following: 1. Information about the HMO and how to contact and obtain information from the HMO, including, but not limited to, the HMO's legal name, its trade name, and phone, fax and e-mail numbers by which consumers and members may cont…

(a) With respect to information about the HMO, the name, address and telephone number of the HMO shall be included, with a telephone number by which members may contact the HMO without incurring toll charges. (b) With respect to eligibility requirements, the plan documents shall …