New Jersey Administrative Code

(a) Every carrier shall establish and implement written policies and procedures regarding the rights of covered persons and the implementation of these rights. (b) Carriers' policies and procedures shall address at least the following: 1. The right of covered persons to receive a…

(a) If a carrier's policy or contract provides benefits for emergency or urgent care services, the carrier shall include benefits for the coverage of trauma services at any designated Level I or II trauma center as medically necessary, which shall be continued at least until, in …

(a) The Commissioner may issue an order directing a carrier to cease and desist from an act or omission that violates a provision of the rules of this chapter that are applicable to the carrier, which order shall serve as constructive written notice to the carrier of an intent to…

(a) The purpose of this subchapter is to implement N.J.S.A. 26:2S-39, and having concluded a study and issued a report to the Governor and Legislature demonstrating that such a regulation is necessary, provide that health benefit plans delivered, issued, executed, or renewed in t…

Except in the case of a religious employer that is granted an exclusion, pursuant to N.J.A.C. 11:24A-24.3, a carrier shall provide coverage, without limit or exclusion, for medical and surgical abortion in accordance with this subchapter. A carrier may apply cost sharing, includi…

(a) A religious employer may request, and a carrier shall grant, an exclusion for medical and surgical abortion coverage, if coverage conflicts with the religious employer's bona fide religious beliefs and practices. An exclusion granted pursuant to this section shall not be cons…

(a) This subchapter shall apply to all carriers that incorporate UM in the administration of one or more of their health benefits plans that have been or will be delivered or offered for delivery in this State. (b) This subchapter shall apply to all health benefits plans in which…

(a) In addition to the requirements of N.J.A.C. 11:24A-2.3, carriers shall include in the disclosure statements a covered person's right to appeal to the carrier an adverse benefit determination, except where the adverse benefit determination was based on eligibility, including r…

(a) The carrier shall designate a physician licensed to practice medicine in New Jersey to serve as the medical director for the carrier with respect to its contracts or policies delivered in this State to which a utilization management program applies. (b) The medical director s…

(a) A carrier's UM program shall be under the direction of the medical director, or his or her designee (who shall be a physician licensed to practice medicine in the State of New Jersey), and shall be based on a written plan, reviewed annually by the carrier, and available for r…

(a) A carrier shall establish an appeal process whereby a covered person or a provider acting on behalf of the covered person, with the covered person's consent, may appeal an adverse benefit determination, except where the adverse benefit determination was based on eligibility, …

(a) Any covered person, and any provider acting on behalf of a covered person with the covered person's consent, may appeal a final internal adverse benefit determination, except where the final internal adverse benefit determination was based on eligibility, including rescission…

(a) A carrier shall provide benefits (including authorization of a service or supply and payment of the claim) pursuant to the IURO's determination and comply with the IURO's determination without delay, but no later than 10 business days from receipt of the IURO's determination,…

(a) Carriers shall have or employ a CQI program to monitor the quality of their UM program under the direction of the carrier's medical director. (b) A carrier shall set forth its system for its CQI program in a plan reviewable upon request by the Department specifying the follow…

(a) This subchapter shall apply to all carriers that have delivered, will deliver or offer for delivery in this State a health benefits plan that is a managed care plan. (b) This subchapter shall apply to the health benefits plans that have been or will be delivered or offered fo…

(a) A carrier shall maintain an adequate network, as set forth in (b) below, of PCPs, specialists and other ancillary providers to assure that covered persons are able to access services in-network and take full advantage of the in-network benefits levels when the policy or contr…

(a) A carrier shall comply with N.J.A.C. 11:24A-3.4. (b) In addition to (a) above, the carrier shall comply with the following: 1. The carrier shall develop its UM criteria and protocols with involvement from its participating providers in accordance with N.J.A.C. 11:24A-4.1 4; a…

(a) A carrier shall establish an internal appeal mechanism whereby a covered person or a provider acting on behalf of a covered person, with the covered person's consent, may appeal any decision to deny, reduce or terminate services or the payment of benefits therefor covered und…

(a) In addition to complying with N.J.A.C. 11:24A-3.8, carriers shall comply with the requirements of N.J.A.C. 11:24-7.1 not otherwise included in N.J.A.C. 11:24A-3.8. (b) A carrier shall have performed and shall submit to the Department, by May 1, 2002 or entrance of the carrier…

(a) A carrier shall develop written clinical criteria and protocols and shall base its UM determinations upon such clinical criteria and protocols. 1. The carrier shall develop its clinical criteria and protocols with the input of practicing physicians and other health care provi…

(a) Both primary contractor and secondary contractor agreements shall be consistent with laws regarding confidentiality of information and shall not be so worded that compliance with the terms of the contract would cause any health care provider to violate his or her professional…

(a) Carriers shall comply with the requirements of N.J.A.C. 11:24-11.7, submitting the information in conjunction with their financial statements required to be filed annually on March 1. 1. For purposes of complying with this requirement, carriers shall submit information for al…

(a) A carrier may offer a managed care plan with a gatekeeper system, but a managed care plan with a gatekeeper system shall not be the only type of managed care plan that the carrier offers in this State, except as (b) below may apply to the carrier. (b) A carrier that offers a …

(a) Carriers shall provide to a covered person no later than the effective date of coverage a current directory of participating providers. Carriers shall, annually thereafter, provide written notice to covered persons that the carrier's current directory is available on its webs…

(a) Carriers shall, upon request, provide a written document to consumers setting forth the information required to be disclosed pursuant to N.J.A.C. 11:24A-4.2(a) through (c). 1. The carrier shall not be required to provide the consumer with the same level of detail that is prov…

Carriers shall submit the forms of the written disclosures required to be made pursuant to N.J.A.C. 11:24A-4.2 and 4.3 for filing with the Department, in accordance with N.J.A.C. 11:24A-2.4 and may use such forms until disapproved by the Department, except as N.J.A.C. 11:24A-4.2(…

(a) The carrier shall designate a physician licensed to practice medicine in New Jersey to serve as the medical director for the carrier with respect to its contracts or policies delivered in this State to which a utilization management program applies. (b) The medical director s…

(a) A carrier shall establish and maintain a system for the presentation and resolution of complaints brought by covered persons regarding the carrier's contracts or policies, choice and accessibility of network providers, and network adequacy, incorporating to the satisfaction o…

(a) A carrier shall establish a committee to review applications submitted by licensed providers to become members of the carrier's network. 1. The carrier may combine the functions of this committee with another committee, so long as when performing its application review functi…

(a) A carrier shall give a health care professional written notice at least 90-days prior to termination of the provider's contract, specifying the health care professional's right to a hearing before a panel appointed by the carrier. 1. The carrier shall set forth in writing the…

(a) A health care professional shall have the right to request a hearing in writing with respect to termination of the health care professional from a carrier's network within 10 business days following the date of the notice. 1. A contract shall be deemed to have terminated, cre…

(a) The Department shall be responsible for the operation of the Independent Health Care Appeals Program. 1. The Department shall combine the Independent Health Care Appeals Program with the External Appeals program set forth under N.J.A.C. 11:24-8.7, but, in accordance with the …

(a) The Department shall periodically review records of carrier reports submitted pursuant to N.J.A.C. 11:24A-3.7 to determine whether a carrier exhibits a pattern of noncompliance with the recommendations of an IURO as well as possible violations of patient rights or other appli…

(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) This chapter shall apply to all organized delivery systems required by the Act to become a certified organized delivery system, and to all organized delivery systems required by the Act to become licensed, except where the language of the chapter clearly indicates otherwise. …

The following words and terms, as used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Act" means P.L. 1999, c. 409; as codified, N.J.S.A. 17:48H-1 et seq., enacted January 18, 2000, and any subsequent amendments. "Affiliate" m…

No ODS required to become a CODS in accordance with N.J.A.C. 11:24B-2.1 shall execute or renew a contract with a carrier as a CODS unless the ODS has filed a complete application for certification in accordance with the requirements of this chapter, and the application has been a…

(a) The Department may suspend or revoke the certification of a CODS upon a finding that: 1. The ODS is operating in contravention of its basic organizational documents; 2. The ODS is unable to fulfill its obligations to the carriers with which it has contracted; 3. The continued…

The Department may suspend or revoke the license of an LODS for the reasons set forth at N.J.A.C. 11:24B-1.4(a). Notes N.J. Admin. Code § 11:24B-1.5

(a) The Department may assess a penalty of not less than $ 250.00 nor more than $ 10,000 against a CODS for each day that the CODS is in violation of the Act or rules promulgated pursuant thereto, in lieu of, or in addition to, suspension or revocation of a certification. (b) The…

(a) A CODS shall maintain confidentially any data or information relating to the diagnosis, treatment, or health of a carrier's covered persons, or prospective covered persons, obtained from the carrier, a provider, or from the individual, and shall not disclose such information …

(a) The Department shall maintain personal information contained in biographical affidavits confidentially to prevent violation of citizens' reasonable expectations of privacy in accordance with N.J.S.A. 47:1A-1. For purposes of this chapter, an affiant's name shall not be consid…

No ODS shall maintain contracts, either directly or indirectly, with a carrier with respect to a health benefits plan for the performance of provision of services set forth at N.J.A.C. 11:24B-2.4(a) unless the ODS is certified or licensed by the Department. Notes N.J. Admin. Code…

(a) The obligation to submit an application for certification arises when a person otherwise meeting the definition of an ODS elects to enter into contracts with one or more carriers directly, rather than solely contracting with carriers through another ODS, and the ODS assumes n…

(a) The Department shall determine whether an application is disapproved as incomplete within 30 days of the date of receipt of the application, and shall notify the ODS in writing of a determination of incompleteness, specifying the items that the ODS shall submit in order to ma…

(a) CODS shall file applications for certification with the Department at the following address: Attn: ODS Certification New Jersey Department of Banking and Insurance Market Regulation PO Box 329 Trenton, NJ 08625-0329 (b) The CODS shall submit an application for certification n…

(a) Every ODS shall submit the following information: 1. A completed Application Cover Sheet, which can be found on the Department's website: www.state.nj.us/dobi/formlist.htm; 2. A completed Irrevocable Consent to Jurisdiction of the Commissioner and New Jersey Courts, which can…