New Jersey Administrative Code

(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…

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