New Jersey Administrative Code

Each HMO shall establish and maintain an informal internal appeal process (stage 1 appeal) whereby any member, or any provider acting on behalf of a member, with the member's consent, who is dissatisfied with any HMO adverse benefit determination, except where the adverse benefit…

(a) Each HMO shall establish and maintain a formal internal appeal process (stage 2 appeal) whereby any member covered by a group health benefits plan or any provider acting on behalf of a member covered by a group health benefits plan with the member's consent, who is dissatisfi…

(a) Any HMO member, and any provider acting on behalf of a member, with the member's consent, may appeal a final internal adverse benefit determination, except where the adverse benefit determination was based on a determination of group or member ineligibility, including resciss…

(a) The Department shall, from time to time, enter into contracts with as many independent utilization review organizations as it deems necessary to conduct the external appeals provided for under N.J.A.C. 11:24-8.7. The physician reviewers of the IUROs selected by the Department…

(a) Pursuant to N.J.S.A. 26:2S-14.1 and 45:9-22.26 and applicable rules of the Department of Health and the Board of Medical Examiners, respectively, all general hospitals licensed pursuant to N.J.S.A. 26:2H-12 et seq. and all physicians licensed pursuant to N.J.A.C. 13:35 are re…

(a) The HMO shall establish and implement written policies and procedures regarding the rights of members and the implementation of these rights. (b) The HMO shall provide each member with a current copy of a member's benefit handbook, including at least: 1. A complete statement …

(a) The purpose of this subchapter is to establish procedures for the Insurance Claims Ombudsman to exercise his or her statutory authority to: 1. Investigate consumer complaints involving policies of insurance, including the payment of claims; 2. Monitor the implementation of N.…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Claim" means any claim filed under a policy of insurance issued pursuant to N.J.S.A. 17:17-1 et seq., 39:6A-1 et seq., or any policy of…

(a) Upon the request of a consumer, the Ombudsman may conduct a review of any disputed insurance claim settlement where there is reasonable cause to believe that an insurer has failed or refused to settle a claim in accordance with the provisions of the policy or has engaged in a…

When deemed necessary to any inquiry undertaken pursuant to this subchapter, the Ombudsman may, in accordance with N.J.S.A. 17:29E-3b, engage the services of consultants and other professionals to assist in the investigation or understanding of any relevant issue, pursuant to all…

(a) The Ombudsman may, upon his or her initiative, or upon the filing of a complaint by any interested party, conduct an investigation and/or hearing into an insurer's trade practices, including claims settlement practices, and marketing practices which may deviate from N.J.S.A. …

(a) The Ombudsman shall maintain a central registry of all closed complaint investigations that shall contain information on the nature of the investigation, findings and disposition. The Ombudsman shall report to the Commissioner any evidence that an insurer may be engaged in a …

(a) Every buyer's guide given to insureds in accordance with Title 11 of the New Jersey Administrative Code shall contain a notice describing the existence and function of the Office of Insurance Claims Ombudsman together with the mailing address, toll-free telephone number and e…

(a) The purpose of this subchapter is to implement the provisions of N.J.S.A. 17:29E-9, that requires life, property and casualty insurers to establish an internal appeals procedure for consumers seeking review of disputed claims. (b) This subchapter shall apply to all disputed c…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Claim" means any claim filed under a policy of insurance issued pursuant to N.J.S.A. 17:17-1 et seq., 39:6A-1 et seq., or any policy of…

(a) Every insurer shall establish and maintain an internal appeals system to provide for the presentation and review of complaints brought by a consumer. All internal appeals procedures shall, at a minimum, include the following components: 1. A system to record and document the …

The internal appeals review shall be conducted by a panel of at least three of the insurer's employees who possess experience and expertise in claims procedures but are not assigned to day-to-day claims payment and adjustment. Notes N.J. Admin. Code § 11:25-2.4

(a) All insurers shall provide policyholders and claimants with a written explanation of the insurer's internal appeals system which is consistent with this subchapter, including any pertinent telephone numbers, fax numbers, e-mail addresses (if used) and business addresses to wh…

Notes N.J. Admin. Code § 11:25-2.6 Repealed by R.2011 d.166, effective 6/6/2011. See: 42 N.J.R. 1981(a), 43 N.J.R. 1350(a). Section was "Reporting".

Failure to comply with the provisions of this subchapter and N.J.A.C. 11:25-1.7 shall subject the insurer to penalties as provided by N.J.S.A. 17:29E-14. Notes N.J. Admin. Code § 11:25-2.7 Amended by R.2007 d.156, effective 5/7/2007. See: 38 N.J.R. 4166(a), 39 N.J.R. 1737(b). Ins…

The purpose of this chapter is to implement the New Jersey Medical Care Access and Responsibility and Patients First Act, P.L. 2004, c. 17 as it applies to insurers authorized to transact medical malpractice liability insurance in this State. Notes N.J. Admin. Code § 11:27-1.1…

This chapter applies to all insurers authorized to transact medical malpractice liability insurance in this State and to the medical malpractice liability insurance policies issued by such authorized insurers, as more specifically set forth in the subchapters that follow. Notes N…

If any provision of this chapter or its application to any person or circumstance is held to be invalid, the remainder of this chapter and its application to other persons or circumstances shall not be affected. Notes N.J. Admin. Code § 11:27-1.3

The purpose of this subchapter is to establish the requirements that the judgment debtor or the judgment debtor's insurer shall follow in order to post a bond or security pursuant to a structured payment agreement authorized by N.J.S.A. 17:30D-27. Notes N.J. Admin. Code § 11:27-1…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Annuity" means an annuity issued by an insurer licensed or authorized to do business in this State, which is a qualified assignment und…

(a) Pursuant to N.J.S.A. 17:30D-27, the judgment debtor or the judgment debtor's insurer shall post a bond or security or, with the written consent of the judgment creditor, assign, as set forth in (b) below, its periodic payment obligations to an insurer authorized to write insu…

(a) The purpose of this subchapter is to establish reporting requirements regarding reinsurance agreements and loss reserves established by insurers that are writing medical malpractice liability insurance in this State. (b) Except as set forth in this subchapter, this subchapter…

The words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Department of Banking…

(a) No later than the earlier of 60 days after the effective date of or 30 days after the execution of a new, renewal of or amendment to any ceded reinsurance contract covering medical malpractice liability insurance, whether such agreement covers medical malpractice liability as…

(a) An insurer transacting medical malpractice liability insurance shall file with the Department by no later than March 15 of each year a copy of the actuarial opinion summary and, by no later than June 1 of each year, a copy of the actuarial report that are maintained pursuant …

All of the documents and information filed pursuant to this subchapter shall be confidential and shall not be deemed a public record for purposes of the Open Public Records Act, N.J.S.A. 47:1A-1 et seq. Notes N.J. Admin. Code § 11:27-11.5

Failure to comply with the provisions of this subchapter shall result in the imposition of penalties pursuant to law, including, but not limited to, penalties set forth in N.J.S.A. 17:33-2. Notes N.J. Admin. Code § 11:27-11.6

(a) The purpose of this subchapter is to set forth minimum requirements for the independence of the board of directors and the committees of the board of directors of an insurer that is writing medical malpractice liability insurance in this State. (b) This subchapter shall apply…

The following words and terms, as used in this subchapter, shall have the following meaning, unless the context clearly indicates otherwise. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Control," "controlling" or "controlled by" ar…

Not less than one-third of the directors of an insurer, and not less than one-third of the members of each committee of the board of directors of any insurer, shall be persons who are not officers or employees of that insurer or of any entity controlling, controlled by, or under …

(a) The board of directors of an insurer shall establish one or more independent board member committees. Such committees shall be comprised of at least two members and shall be comprised solely of directors who are not officers or employees of the insurer or of any entity contro…

Failure to comply with the provisions of this subchapter shall result in the imposition of penalties as authorized by law, including, but not limited to, the penalties authorized by N.J.S.A. 17:33-2. Notes N.J. Admin. Code § 11:27-12.5

(a) The purpose of this subchapter is to provide for the biannual reporting of information related to rate modifiers used by medical malpractice liability insurers writing physicians and surgeons coverage in this State. (b) This subchapter shall apply to all insurers authorized t…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Department" means the New Jersey Department of Banking and Insurance. "Insurer" means an insurer authorized to transact medical malprac…

(a) All insurers shall file with the Department biannually the information set forth in Exhibit 1 in the Appendix to this subchapter, incorporated herein by reference, no later than August 1 and February 1 of each year, for the immediately preceding six month periods of January 1…

Failure to comply with the provisions of this subchapter shall result in the imposition of penalties as authorized by law, including, but not limited to, penalties authorized pursuant to N.J.S.A. 17:33-2. Notes N.J. Admin. Code § 11:27-13.4

(a) This subchapter sets forth: 1. The procedures by which the Commissioner shall establish the designated range of annual rate change that may become effective 30 days after filing pursuant to N.J.S.A. 17:29AA-5.1; 2. The filing requirements for changes in rates for medical malp…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Department …

(a) The Commissioner shall designate the range of annual rate change pursuant to N.J.S.A. 17:29AA-5.1 as set forth in this section. 1. If the Commissioner finds that either of the following conditions exist, then the range of annual rate change shall be plus or minus five percent…

(a) The Commissioner's findings as provided in N.J.A.C. 11:27-14.3 shall be made no less frequently than once every three years as follows: 1. The Department shall issue a public notice setting forth the Commissioner's proposed findings in accordance with N.J.A.C. 11:27-14.3 purs…

Any medical malpractice liability insurance rate changes, unless such are required to be filed for prior approval pursuant to this subchapter, shall be filed with the Department no later than 30 days prior to the implementation thereof, and thereafter may be implemented unless di…

(a) Any insurer or rating organization seeking to change or modify its rating system for medical malpractice liability insurance shall provide the following information in support of its application: 1. A narrative overview that sets forth the contents of the filing, and explains…

(a) In computing any period of time fixed by this subchapter, the day of the act or event from which the designated period begins to run is not to be included. The last day of the period so computed is to be included, unless it is on a Saturday, Sunday or legal holiday, in which …

Any change to an insurer's or rating organization's rating system that has no impact on premiums charged (for example, a company introduces a new limit and factor with no impact on premium) shall be filed with the Department for review no later than 30 days prior to the implement…

Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including, but not limited to, those penalties authorized pursuant to N.J.S.A. 17:33-2. Notes N.J. Admin. Code § 11:27-14.9