New Jersey Administrative Code

(a) Except as set forth in N.J.A.C. 11:24B-2.6, an ODS shall provide the Department with 30 days prior notice of changes to information contained in its certification unless 30 days' prior notice was impossible, in which event, the ODS shall provide notice of the change as soon a…

(a) The certification of an ODS shall expire three years after issuance. A certification shall automatically renew for another three-year period unless the Department finds that the ODS no longer complies with the Act or other applicable law, or if the ODS fails to file a complet…

The fee for review of an application for certification shall be $ 2,500. Notes N.J. Admin. Code § 11:24B-2.9 Repeal and New Rule, R.2009 d.243, effective 8/3/2009. See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a). Section was "ODS: fees".

A carrier's delegation to an ODS of performance of a legal obligation of the carrier established by statute or regulation shall not relieve the carrier of its legal obligation to assure that performance of that obligation occurs consistent with standards established by law, nor s…

In order for an ODS to be certified to perform continuous quality improvement on behalf of a carrier, the ODS shall demonstrate compliance with the requirements of N.J.A.C. 11:24B-3.5(h) and (i). Notes N.J. Admin. Code § 11:24B-3.10 Amended by R.2009 d.243, effective 8/3/2009. Se…

In order for an ODS to be certified to perform provider complaint functions on behalf of a carrier, the ODS shall demonstrate that it is in compliance with the requirements of N.J.A.C. 11:24-3.7(b) or 11:24A-4.6(b). Notes N.J. Admin. Code § 11:24B-3.11 Amended by R.2009 d.243, ef…

In order for an ODS to be certified to perform member complaint functions on behalf of a carrier, the ODS shall demonstrate that it is in compliance with the requirements of N.J.A.C. 11:24-3.7(a) or 11:24A-4.6(a). Notes N.J. Admin. Code § 11:24B-3.12 Amended by R.2009 d.243, effe…

(a) Carriers shall only delegate the performance of those functions set forth at N.J.A.C. 11:24B-2.4(a), as further described in this subchapter, to a CODS certified for those functions. (b) A carrier may contract with an entity to perform less than a majority of the duties speci…

(a) When an LODS or CODS contracts with an HMO to perform one or more of the functions listed in this chapter, the ODS shall comply with the standards applicable to the HMO for that function as set forth in the statutes and/or regulations applicable to HMOs, including, but not li…

(a) In order to qualify for certification to provide or arrange for the provision of the performance of health care services only, an ODS shall: 1. Submit a statement certifying that the ODS shall not engage in the performance of any of the other functions set forth in this chapt…

(a) In order to qualify for certification to perform network management, an ODS shall comply with the requirements of N.J.A.C. 11:24B-3.4(b), and shall perform the following duties, meeting the standards of this section: 1. Recruiting, and maintenance of provider relations system…

(a) If an ODS performs credentialing and recredentialing activities, whether with respect only to the ODS' contracted providers or other providers that may be contracted with the carrier directly or through another ODS, the ODS shall demonstrate that it meets the following requir…

(a) In order for an ODS to be certified to perform development of UM guidelines, the ODS shall comply with the following: 1. The ODS shall designate a medical director to be responsible for its UM guidelines program who is licensed to practice medicine in New Jersey; or acknowled…

(a) In order for an ODS to be certified to operate a utilization management program, the ODS shall comply with the requirements of N.J.A.C. 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f), and:1. Have a mechanism that ensures consistent application of review criteria and uniform d…

In order for an ODS to be certified to perform duties with respect to a carrier's utilization management appeal mechanism, the ODS shall comply with the requirements of N.J.A.C. 11:24-8.4 through 8.6 or 11:24A-3.5 and 4.12, and N.J.S.A. 26:2S-11. Notes N.J. Admin. Code § 11:24B-3…

This subchapter shall apply to all contracts between a carrier and a CODS or LODS, and to all contracts between two or more ODSs, at least one of which is contracted with a carrier for the performance of one or more functions set forth in N.J.A.C. 11:24B-2.4(a). Notes N.J. Admin.…

(a) The contract shall contain provisions demonstrating the ODS' compliance with N.J.A.C. 11:24-3.7(b) or 11:24A-4.6(b) if addressing provider complaints, or N.J.A.C. 11:24-3.7(a) or 11:24A-4.6(a) if addressing complaints of covered persons. (b) The contract shall specify the aut…

(a) No ODS or carrier shall execute a contract or an amendment to a contract for a management agreement unless the form thereof has been approved by the Department. (b) The following are amendments that may be effectuated without approval of the Department: 1. Amendments that are…

(a) Management agreements submitted with the initial application for certification or an application for licensing shall be subject to the standards for submission, review and approval as set forth at N.J.A.C. 11:24B-2. (b) Amendments to forms of management agreements shall be su…

(a) All management agreement forms shall contain the following: 1. A provision specifying that the contract and amendments thereto are subject to prior approval of the Department, and may not be effectuated without such approval. i. The provision may state that the following type…

(a) In addition to complying with N.J.A.C. 11:24B-4.2(a)10, every contract shall specify which terms of the contract survive termination, and the duration of such survival. (b) When an ODS is engaged in network management, the contract shall include a provision for the continuati…

(a) The contract shall detail the functions that the ODS is obligated to perform on behalf of the carrier with respect to network management, including all health care services and supplies the ODS will arrange to have provided to the carrier's covered persons. (b) The contract s…

(a) The contract shall specify the party with which the medical director responsible for the credentialing program is employed or affiliated. (b) The contract shall specify the responsibilities of the ODS and the carrier with respect to the credentialing program, including the tr…

(a) The contract shall detail the services that the ODS is performing on behalf of the carrier, specifying the general areas of health care services for which the UM guidelines are being developed or maintained. (b) The contract shall specify that the ODS is obligated to assure a…

(a) The contract shall specify the features of the ODS' program that assure its compliance with N.J.A.C. 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f) and 4.11(b)2, as appropriate to the carrier with which the ODS is contracted, and the health benefits plans for which UM will be…

(a) The contract shall specify how the ODS will comply with N.J.A.C. 11:24A-3.5, 11:24-8.4 through 8.6 or 11:24A-4.1 2, as applicable. (b) If the ODS and the carrier agree that the ODS will review UM appeals submitted by a provider without requiring the consent of the covered per…

(a) The contract shall contain provisions that assure the ODS' ability to demonstrate compliance with N.J.A.C. 11:24B-3.3(h) and (i), except that, if the ODS is agreeing to perform continuous quality improvement only with respect to health benefits plans that are not managed care…

This subchapter shall apply to all provider agreements for the delivery of one or more health care services to a covered person of a carrier. Notes N.J. Admin. Code § 11:24B-5.1

Notes N.J. Admin. Code § 11:24B-5.10 Repealed by R.2013 d.048, effective 3/18/2013 (operative January 1, 2014). See: 44 N.J.R. 376(a), 45 N.J.R. 651(a). Section was "Review and approval of provider agreements".

(a) All provider agreement forms shall comply with the requirements set forth at N.J.A.C. 11:24C-4 and shall contain: 1. A provision specifying that any sections of the contract that conflict with State or Federal law are effectively amended to conform with the requirements of th…

(a) Provider agreements shall specify the term of the contract, reasons for which the contract may be terminated by one or more parties to the contract, procedures for notice and effectuation of such termination, and opportunities, if any, to cure any deficiencies prior to termin…

(a) Provider agreements shall specify the term of the contract, reasons for which the contract may be terminated by one or more parties to the contract, procedures for notice and effectuation of such termination, and opportunities, if any, to cure any deficiencies prior to termin…

(a) The contract shall specify the mutual responsibility of the provider and carriers to assure 24-hour, seven-day per week emergency and urgent care coverage to covered persons, and the procedures to assure proper utilization of such coverage. (b) The contract shall specify the …

(a) The contract shall specify the obligation of the facility to follow clear procedures for granting of admitting and attending privileges, and to notify the ODS and/or carrier when such procedures change. 1. If notification must be made separately to one or more carriers, this …

(a) There shall be a provision specifying that the carrier is a third party beneficiary of the provider agreement, with privity of contract, and a right to enforce the provisions of the provider agreement in the event that the ODS fails to do so, except that such a provision is n…

Notes N.J. Admin. Code § 11:24B-5.8 Repealed by R.2013 d.048, effective 3/18/2013 (operative January 1, 2014). See: 44 N.J.R. 376(a), 45 N.J.R. 651(a). Section was "Use of contract addenda to reflect requirements alternating by carrier".

Notes N.J. Admin. Code § 11:24B-5.9 Repealed by R.2013 d.048, effective 3/18/2013 (operative January 1, 2014). See: 44 N.J.R. 376(a), 45 N.J.R. 651(a). Section was "Issuance of contracts on approved forms".

(a) This subchapter applies to all carriers offering managed care plans, and the agents that carriers may use for purposes of credentialing or recredentialing physicians on behalf of the carriers. (b) This subchapter establishes a credentialing and recredentialing form pursuant t…

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 authorized to transact the business of insurance in this State and doing a health insurance busines…

(a) For providers using the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource, carriers shall complete provider credentialing within 90 days of receipt of a complete credentialing application in accordance with this subchapter. 1. Within 45 days of a …

(a) Carriers that offer managed care plans shall accept the New Jersey Physician Recredentialing Application, as set forth in Exhibit 2 of the Appendix to this subchapter and incorporated herein by reference, for the purposes of recredentialing physicians who seek to continue to …

(a) Use or acceptance by a carrier of the New Jersey Universal Physician Application form, the New Jersey Physician Recredentialing form or the election by the carrier to obtain information from a national credentialing database, data bank or repository of health care providers s…

(a) The Department is authorized to impose the following remedies to enforce the provisions of these rules.1. Imposition of a monetary penalty for each violation in an amount determined by the Commissioner in accordance with N.J.S.A. 26:2S-16; and/or 2. Other remedies for violati…

(a) This subchapter shall apply to all carriers offering health benefits plans that are managed care plans, and to all such health benefits plans offered by a carrier. (b) This subchapter shall apply to all persons desiring to contract with carriers for the provision of home trea…

(a) A designated health care provider may lose its designation as the result of one or more of the following: 1. Revocation, suspension or surrender of a registration with respect to a health care service firm; 2. Revocation, suspension or surrender of a license with respect to h…

(a) When loss of designation results from a situation set forth at N.J.A.C. 11:24C-2.1 0(a)1, 2 or 3, the health care provider shall cease providing home treatment for bleeding episodes associated with hemophilia immediately. 1. The health care provider shall coordinate with the …

(a) Every designated health care provider shall have an affirmative obligation to provide notice to the Department about any material change in the information provided to the Department on which the health care provider's designation was based. 1. Health care providers shall rep…