Title 17, Title 17: CORPORATIONS AND INSTITUTIONS FOR FINANCE AND INSURANCE

17:48G-3 Dental decisions made by third party administrator. 3. a. A third party administrator may make dental decisions in connection with the processing or payment of dental claims or otherwise in the course of its dental benefit administration activity. Dental decisions made b…

17:48G-4 Inapplicability of act relative to certain decisions of insurers, third party administrators. 7. This act shall not be construed: a. To regulate insurers' or third party administrators' making any decision, including, but not limited to, a decision concerning benefit or …

17:48G-5 Applicability of act to dental decisions. 8. This act shall be construed to apply only to insurers and third party administrators or persons acting on their behalf who make dental decisions. L.2007, c.259, s.8.

17:48G-6 Construction of act relative to board. 9. Nothing in this act shall be construed to confer jurisdiction upon the board to make any dental benefit coverage determinations or to direct any insurer, benefit plan, administrator or other payor to make any payment or otherwise…

17:48H-1 Definitions relative to organized delivery systems for health care services benefits. 1. As used in this act: "Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the o…

17:48H-10 Civil administrative penalty. 10. The Commissioner of Banking and Insurance may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $250 nor more than $10,000 for each day that a certified organized delivery system is in violation …

17:48H-11 Application for licensure. 11. a. An organized delivery system which receives compensation on a basis that entails the assumption of financial risk shall submit an application for licensure to the Commissioner of Banking and Insurance. The organized delivery system may …

17:48H-12 Form, contents of application. 12. Application for a license to operate an organized delivery system shall be made to the Commissioner of Banking and Insurance on a form prescribed by the commissioner, shall be certified by an officer or authorized representative of the…

17:48H-13 Review of application. 13. Following receipt of an application for licensure, the Commissioner of Banking and Insurance shall review it and notify the applicant of any deficiencies contained therein. a. The Commissioner of Banking and Insurance shall issue a license to …

17:48H-14. Notice of change, modification 14. a. A licensed organized delivery system, unless otherwise provided in this act, shall not materially modify any matter or document furnished pursuant to section 12 of this act, unless the system files with the Commissioner of Banking …

17:48H-15 Services provided by licensed organized delivery system. 15. A licensed organized delivery system may: a. Contract with an insurer licensed in this State for the provision of indemnity coverage against the cost of services provided by the system or other obligations of …

17:48H-16. Treatment of organized delivery system as domestic insurer 16. a. A licensed organized delivery system which is organized under the laws of this State shall be treated as a domestic insurer for the purposes of P.L.1970, c.22 (C.17:27A-1 et seq.) and P.L.1992, c.65 (C.1…

17:48H-17. Examination of licensed organized delivery system 17. The Commissioner of Banking and Insurance may conduct an examination of a licensed organized delivery system as often as the commissioner deems necessary in order to protect the interests of providers, contract hold…

17:48H-18. Contracts with providers, mandatory terms 18. All licensed organized delivery system contracts with providers shall contain the following terms and conditions: a. In the event that the organized delivery system fails to pay or provide for comprehensive or limited healt…

17:48H-19. Minimum net worth 19. a. 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 established by the Commissioner of Banking and Insurance by regulation, which amount may v…

17:48H-2. Certification, licensure, required 2. a. Beginning one year after the enactment of this act, no person, corporation, partnership, or other entity shall operate an organized delivery system in this State without obtaining certification or licensure pursuant to this act. …

17:48H-20. Deposit of cash, securities 20. a. A licensed organized delivery system shall deposit with the Commissioner of Banking and Insurance, or with an entity or trustee acceptable to the commissioner through which a custodial or controlled account is utilized, cash, securiti…

17:48H-21 Maintenance of fidelity bond 21. A licensed organized delivery system shall maintain in force a fidelity bond in its own name on its officers and employees, in an amount established by the Commissioner of Banking and Insurance by regulation. L.1999,c.409,s.21.

17:48H-22. Annual report 22. A licensed organized delivery system shall file an annual report with the Commissioner of Banking and Insurance, on or before March 1 of each year, attested to by at least two principal officers, which covers the preceding calendar year. The report sh…

17:48H-22.1 Definitions. 41. As used in sections 41 through 45 of P.L.2014, c.81 (C.17:48H-22.1 through C.17:48H-22.5): "Commissioner" means the Commissioner of Banking and Insurance. "Licensed organized delivery system" means an entity authorized to transact business in this Sta…

17:48H-22.2 Increase in amount of capital or surplus required of licensed organized delivery system. 42. The commissioner may increase the amount of capital or surplus required of a licensed organized delivery system, or subsequently revise or redetermine that increase, using app…

17:48H-22.3 Determination of increase, revision or redetermination; factors. 43. In determining any increase, revision or redetermination in the capital or surplus of a licensed organized delivery system pursuant to the provisions of section 42 of P.L.2014, c.81 (C.17:48H-22.2) t…

17:48H-22.4 Suspension, revocation of authority to do business. 44. The commissioner may suspend or revoke the authority to do business in this State of any licensed organized delivery system that does not comply with the provisions of sections 41 through 45 of P.L.2014, c.81 (C.…

17:48H-22.5 Rules, regulations. 45. The commissioner may promulgate regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of sections 41 through 45 of P.L.2014, c.81 (C.17:48H-22.1 through C.17:48H-22…

17:48H-23. Suspension, revocation of license, grounds 23. The Commissioner of Banking and Insurance may suspend or revoke the license issued to an organized delivery system pursuant to this act upon the commissioner's determination that: a. The licensed organized delivery system …

17:48H-24. Notification of grounds for suspension, revocation of license 24. a. If the Commissioner of Banking and Insurance has cause to believe that grounds exist for the suspension or revocation of a license, the commissioner shall notify the licensed organized delivery system…

17:48H-25. Plan for insolvency, insurance 25. The Commissioner of Banking and Insurance may require, in connection with the plan for insolvency required pursuant to paragraph (5) of subsection i. of section 12 of this act, that a licensed organized delivery system maintain insura…

17:48H-26. Rehabilitation, liquidation, conservation of licensed organized delivery system 26. Any rehabilitation, liquidation or conservation of a licensed organized delivery system shall be subject to the provisions of P.L.1992, c.65 (C.17B:32-31 et seq.) and shall be conducted…

17:48H-27. Licensed organized delivery system exempt from guaranty association act, C.17B:32A-1 et seq. 27. A licensed organized delivery system shall not be subject to the "New Jersey Life and Health Insurance Guaranty Association Act," P.L.1991, c.208 (C.17B:32A-1 et seq.), and…

17:48H-28. Fees 28. A licensed organized delivery system shall pay to the Commissioner of Banking and Insurance those application and examination fees as are established by the commissioner by regulation in the same manner as established for insurers and health maintenance organi…

17:48H-29. Civil administrative penalty 29. The Commissioner of Banking and Insurance may, upon notice and hearing, assess a civil administrative penalty in an amount not less than $250 nor more than $10,000 for each day that a licensed organized delivery system is in violation o…

17:48H-3 Application for certification. 3. a. An organized delivery system which is not subject to licensure requirements pursuant to this act shall submit an application for certification to the Commissioner of Banking and Insurance. The organized delivery system may continue to…

17:48H-30. Confidentiality of data, information; exceptions 30. Any data or information relating to the diagnosis, treatment or health of an enrollee, prospective enrollee or contract holder obtained by a certified or licensed organized delivery system from the carrier, contract …

17:48H-31 Notification of change of means for receipt of compensation. 31. Any certified organized delivery system which intends to change the means by which it receives compensation so that it will be compensated on a basis that entails the assumption of financial risk shall mak…

17:48H-32 Rules, regulations. 32. The Commissioner of Banking and Insurance shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to effectuate the purposes of this act. The commissioner shall adopt the rules and r…

17:48H-33 Applicability of health care quality act. 33. An organized delivery system which is licensed by the Department of Banking and Insurance shall be subject to the "Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et seq.) and the regulations promulgated thereunder. L.1…

17:48H-33.1 Adoption, implementation of standards by organized delivery system for electronic transactions. 1. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), an organized delivery system which is either…

17:48H-33.2 Organized delivery system subject to regulations under C.17B:30-26 et seq. 2. An organized delivery system which is either certified or licensed pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.) shall be subject to the provisions of P.L.1999, c.155 (C.17B:30-26 et seq.…

17:48H-34. Provision of data, reports 34. a. A carrier that contracts with a licensed organized delivery system shall provide that system with any data or reports required by their contractual arrangement on a timely basis, in accordance with the terms of the contract. b. If a ca…

17:48H-35 Documents deemed proprietary, confidential. 35. Any documents provided by a organized delivery system to the Department of Banking and Insurance pursuant to this act that are deemed by the Commissioner of Banking and Insurance to be proprietary, shall be confidential an…

17:48H-4 Form, contents of application. 4. Application for certification to operate an organized delivery system shall be made to the Commissioner of Banking and Insurance on a form prescribed by the commissioner, shall be certified by an officer or authorized representative of t…

17:48H-5 Review of application. 5. Following receipt of an application for certification, the Commissioner of Banking and Insurance shall review it and notify the applicant of any deficiencies contained therein. a. The Commissioner of Banking and Insurance shall issue a certifica…

17:48H-6 Notice of change, modification. 6. a. A certified organized delivery system, unless otherwise provided for in this act, shall not materially modify any matter or document furnished to the Commissioner of Banking and Insurance pursuant to section 4 of this act unless the …

17:48H-7 Suspension, revocation of certification, grounds. 7. The Commissioner of Banking and Insurance may suspend or revoke a certification issued to an organized delivery system pursuant to this act upon the commissioner's determination that: a. The certified organized deliver…

17:48H-8 Notification of grounds for suspension, revocation of certification. 8. a. If the Commissioner of Banking and Insurance has cause to believe that grounds exist for the suspension or revocation of the certification issued to an organized delivery system, the commissioner …

17:48H-9 Fees. 9. A certified organized delivery system shall pay to the Commissioner of Banking and Insurance those application and examination fees as are established by the commissioner by regulation. L.1999, c.409, s.9; amended 2012, c.17, s.45.