New Jersey Administrative Code

(a) No carrier shall arrange with any person for the provision of home treatment of bleeding episodes associated with hemophilia unless that person shall be a designated health care provider of such services. (b) Carriers with an aggregate enrollment of 50,000 covered persons or …

(a) A person seeking to become a designated health care provider shall submit to the Department an original and at least one copy of an application at the following address: Mailing Address (U.S. Postal Service): NJ Department of Banking and Insurance Consumer Protection Services…

(a) The applicant shall submit copies of all registrations, licenses and permits issued to the applicant by the State of New Jersey pursuant to Title 45 and Title 26 of the New Jersey Statutes, and shall demonstrate that the applicant is in good standing with respect to such lice…

(a) The Department shall review applications to determine whether they are complete. (b) If the Department determines that an application is incomplete, the Department shall provide a written notice to the applicant of this determination with an explanation of why the application…

(a) The Department may request additional information from the applicant notwithstanding a determination that the application is complete, if the Department believes such information is relevant to the Department's review of the application. (b) The Department may consider additi…

(a) An applicant shall possess a pharmacy permit issued by the New Jersey Board of Pharmacy pursuant to N.J.A.C. 13:39-4, which may be a specialized permit issued in accordance with N.J.A.C. 13:39-4.1 6. 1. With respect to the applicant's pharmacy permit, at least some portion of…

(a) No later than April 1 of each year, a designated health care provider shall submit an annual report for the immediately preceding calendar year, which shall include the following: 1. The number of patients served with the number of units of blood clotting factors shipped; 2. …

(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 applies only with respect to the provision of services for treatment of hemophilia, and does…

A carrier that violates any provisions of this subchapter shall be subject to fines and other penalties available pursuant to N.J.S.A. 26:2S-16; however, a carrier shall not be determined to be in violation of the provisions of the subchapter that require contracting with and ref…

For the purposes of this subchapter, the words and terms set forth below 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 insur…

(a) Every carrier shall provide for, in its managed care plans, in-network benefits or services for the home treatment of bleeding episodes associated with hemophilia. (b) No carrier shall arrange with any person for the provision of home treatment of bleeding episodes associated…

(a) When a designated health care provider with which the carrier has arranged for the provision of services and supplies for the home treatment of bleeding episodes associated with hemophilia loses designation, the carrier shall not continue to refer covered persons to the servi…

(a) In the event that a carrier or a designated health care provider terminate their agreement for, or which includes among its terms, the provision of services and supplies to a carrier's covered person for home treatment of bleeding episodes associated with hemophilia, the carr…

(a) The Department shall maintain and make available a list of designated health care providers in accordance with N.J.A.C. 11:24C-2.1 3, and a list of State-recognized outpatient regional hemophilia care centers. (b) Notwithstanding the Department's maintenance of a list of desi…

(a) When a covered person's attending physician determines that a covered person needs to use the services of a clinical laboratory at a State-recognized outpatient regional hemophilia care center because of timing or the need for closely supervised procedures in venipuncture and…

(a) Carriers that have agreements for the provision of services and supplies for home treatment of bleeding episodes associated with hemophilia with one or more persons identified in Bulletin OMC 2001-04 as acceptable health care providers of such services may continue to refer c…

Notes N.J. Admin. Code § 11:24C-3.9 Repealed by R.2009 d.195, effective 6/15/2009. See: 40 N.J.R. 6922(a), 41 N.J.R. 2491(a). Section was "Identification of hemophilia health care providers by carrier".

(a) The purpose of this subchapter is to establish standards relating to agreements entered into between carriers and health care providers. (b) This subchapter shall apply to all insurance companies, health service corporations, hospital service corporations, medical service cor…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Adverse change" or "adverse amendment" means any action taken by a carrier that that could reasonably be expected to have a material adv…

(a) Unless otherwise provided by statute and except as set forth in this section, no agreement between a participating provider and a carrier shall be subject to prior approval by the Commissioner. In the case of HMOs, only the proposed form of provider agreement submitted to the…

When participating providers are reimbursed on a basis other than fee-for-service (for example, capitation, per diem, or percent of charges), the agreement shall specify the dollar amount or methodology used by the carrier to determine reimbursement, and identify the services inc…

(a) Carriers shall maintain accurate and current information on all providers, and make that information available to members and prospective members through network directories, as described in this section. (b) Directories shall include, at a minimum, the following information …

(a) Carriers shall implement a system for maintaining accurate and current information on all providers listed in a network directory. (b) Carriers shall ensure the information in the provider directory is based on the most recently submitted information from the provider or the …

(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 …