reglab/housing_qa huggingface dataset:
NJ Rev Stat § 17:48F-19 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-19 - Notification of suspension, revocation of certificate of authority.

17:48F-19 Notification of suspension, revocation of certificate of authority.  19. If the commissioner has cause to believe that grounds exist for the suspension or revocation of a certificate of authority, he shall notify the prepaid prescription service organization in writing, specifically stating the grounds for suspension or revocation and fixing a time for a hearing in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). If a certificate of authority is revoked, the organization shall submit a plan to the commissioner within 15 days of the revocation, for the winding up of its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of its business. The commissioner may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing prescription services. L.1997,c.380,s.19.
NJ Rev Stat § 17:48F-20 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-20 - Maintenance of insurance to cover insolvency.

17:48F-20 Maintenance of insurance to cover insolvency.  20. The commissioner may require, in connection with the plan for insolvency required pursuant to subsection p. of section 3 of this act, that a prepaid prescription service organization maintain insurance to cover the expenses to be paid for continued benefits following a determination of insolvency, or make other arrangements to ensure that benefits are continued for the period determined in the insolvency plan. L.1997,c.380,s.20.
NJ Rev Stat § 17:48F-21 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-21 - Rehabilitation, liquidation, conservation of prepaid prescription service organization.

17:48F-21 Rehabilitation, liquidation, conservation of prepaid prescription service organization.  21. Any rehabilitation, liquidation or conservation of a prepaid prescription service organization shall be subject to the provisions of N.J.S.17B:32-1 et seq. and shall be conducted under the supervision of the commissioner; except that the commissioner shall have the authority to regulate any prepaid prescription service organization doing business in this State as a domestic insurer. The commissioner may apply for an order directing him to rehabilitate, liquidate, reorganize or conserve an organization upon any one or more applicable grounds as stated for insurers in N.J.S.17B:32-1 et seq. or any other provision of Title 17B of the New Jersey Statutes or when in his opinion the organization fails to satisfy the requirements for the issuance of a certificate of authority relating to solvency or the requirements for solvency protection as set forth in this act. L.1997,c.380,s.21.
NJ Rev Stat § 17:48F-22 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-22 - Order of rehabilitation.

17:48F-22 Order of rehabilitation.  22. If an order of rehabilitation issued pursuant to this act directs or provides for the continued operation of the prepaid prescription service organization, including the receipt of payments from, and the provision of prescription services to enrollees, the order may authorize the rehabilitator to make the payments necessary for continued operation, including those expenses necessary for the conduct of the rehabilitation. L.1997,c.380,s.22.
NJ Rev Stat § 17:48F-23 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-23 - Providers enjoined from billing enrollees, beneficiaries under order of rehabilitation.

17:48F-23 Providers enjoined from billing enrollees, beneficiaries under order of rehabilitation.  23. In the event that an order of rehabilitation or liquidation is granted, the order may enjoin providers from billing enrollees and their beneficiaries for health care services provided. In the course of a rehabilitation proceeding, the court may allow reformation of enrollee and provider contracts, or other restructuring of outstanding liabilities, or transfer of the business to another prepaid prescription service organization. A primary goal of the restructuring or transfer shall be the provision of uninterrupted services to enrollees of the organization. In the course of a rehabilitation proceeding, a plan for settling the claims of general creditors shall not be deemed to be inequitable or to constitute preferential treatment if the amount of reimbursement for an outstanding claim depends, in part, on the estimated increase or decrease in future or prior claims of the creditor. L.1997,c.380,s.23.
NJ Rev Stat § 17:48F-24 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-24 - Inapplicability of C.17B:32A-1 et seq.

17:48F-24 Inapplicability of C.17B:32A-1 et seq.  24. A prepaid prescription service organization 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 the New Jersey Life and Health Insurance Guaranty Association established pursuant to that act shall not provide protection to any individuals entitled to receive prescription services from a prepaid prescription service organization. L.1997,c.380,s.24.
NJ Rev Stat § 17:48F-25 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-25 - Application, examination fees.

17:48F-25 Application, examination fees.  25. A prepaid prescription service organization subject to the provisions of this act shall pay to the commissioner such application fees and examination fees for applying for a certificate of authority as established by regulation by the commissioner. L.1997,c.380,s.25.
NJ Rev Stat § 17:48F-26 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-26 - Violations; penalties.

17:48F-26 Violations; penalties.  26. a. The commissioner may, upon notice and hearing, levy an administrative penalty in an amount not less than $1,000 nor more than $30,000 for each violation, per contract or enrollee. Penalties imposed by the commissioner pursuant to this section may be in lieu of, or in addition to, suspension or revocation of a certificate of authority pursuant to this act. A penalty may be recovered in a summary proceeding pursuant to "the penalty enforcement law," N.J.S.2A:58-1 et seq. b. If the commissioner believes that any violation of this act has occurred or is threatened, the commissioner may give notice to the prepaid prescription service organization, its representatives, or any other persons who appear to be involved in the alleged violation. The commissioner may arrange a conference with the alleged violators or their authorized representatives to ascertain the facts relating to the alleged violation. In the event that it appears that a violation has occurred or is threatened, the commissioner may implement the necessary measures to correct or prevent the violation. Appeals under this section shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). L.1997,c.380,s.26.
NJ Rev Stat § 17:48F-27 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-27 - Cease and desist order; injunctive relief.

17:48F-27 Cease and desist order; injunctive relief.  27. a. The commissioner may issue an order directing a prepaid prescription service organization to cease and desist from engaging in any act or practice which is in violation of the provisions of this act. The order shall be subject to review pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). b. In the event of noncompliance with a cease and desist order issued pursuant to subsection a. of this section, or if the commissioner elects not to issue a cease and desist order in the case of a violation of any provision of this act, the commissioner may institute a proceeding to obtain injunctive relief, in accordance with the applicable procedures provided in the Rules of Court.  L.1997,c.380,s.27.
NJ Rev Stat § 17:48F-28 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-28 - Confidentiality of data, information.

17:48F-28 Confidentiality of data, information.  28. Any data or information relating to the diagnosis, treatment or health of an enrollee or prospective enrollee obtained by a prepaid prescription service organization from the contract holder, enrollee, prospective enrollee or any provider shall be confidential and shall not be disclosed to any person except: a. To the extent that it may be necessary to carry out the purposes of this act; b. Upon the express consent of the enrollee or prospective enrollee; c. Pursuant to statute or court order for the production of evidence or the discovery thereof; or d. In the event of a claim or litigation between an enrollee or a prospective enrollee and the organization wherein such data or information is relevant. An organization shall be entitled to claim any statutory privilege against disclosure which the provider who furnished the information to the organization is entitled to claim. L.1997,c.380,s.28.
NJ Rev Stat § 17:48F-29 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48F-29 - Rules, regulations.

17:48F-29 Rules, regulations.  29. The commissioner 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. L.1997,c.380,s.29.
NJ Rev Stat § 17:48G-1 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-1 - Definitions relative to dental decision regulation.

17:48G-1 Definitions relative to dental decision regulation.  1. As used in this act: "Adverse dental decision" means a dental decision by an insurer or a third party administrator, or any other person acting on its behalf to deny, reduce, or fail to provide payment, in whole or in part, for a covered service based upon a dental decision. "Board" means the New Jersey State Board of Dentistry. "Dental decision" means a decision which is based upon a dental diagnosis or a dental judgment related to dental services performed or to be performed in the State of New Jersey, including, but not limited to, any decision relating to: the quality or appropriateness of dental services rendered or proposed to be rendered by a dentist; reasonable necessity for or customary performance of a dental service; or diagnosis or prognosis of a dental condition. "Insurer" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization or health maintenance organization authorized to issue dental contracts or plans in this State.  "Third party administrator" means "third party administrator" as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1). L.2007, c.259, s.1.
NJ Rev Stat § 17:48G-2 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-2 - Dental decisions made by insurer.

17:48G-2 Dental decisions made by insurer.  2. a. An insurer 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 by an insurer shall be consistent with the following:  (1) an initial adverse dental decision shall be made by a dentist duly licensed in this or another state;  (2) if a treating dentist questions the adverse dental decision and specifies in writing the basis of the disagreement with the adverse dental decision, the insurer, within 30 days shall:  (a) designate a reviewing dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and  (b) notify the treating dentist in writing promptly of the name and address where the reviewing dentist can be contacted and the telephone number which can be used to contact the reviewing dentist; (3) if an agreement is not reached within a reasonable period of time, not to exceed 30 days from the insurer's notice issued pursuant to subparagraph (b) of paragraph (2) of this subsection, the insurer shall make its decision and communicate the results of the reviewing dentist's dental decision to the treating dentist.  b. Within 14 days of a written request by the treating dentist, or the patient or the patient's authorized representative, for the basis of an adverse dental decision by a reviewing dentist, provided to the treating dentist pursuant to paragraph (3) of subsection a. of this section, the insurer shall send a written notice containing the full name, address and telephone number of the reviewing dentist and a narrative statement specifically identifying the basis for the decision.  L.2007, c.259, s.2.
NJ Rev Stat § 17:48G-3 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-3 - Dental decisions made by third party administrator.

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 by a third party administrator shall be consistent with all of the following:  (1) an initial adverse dental decision shall be made by a dentist duly licensed in this or another state; (2) if a treating dentist questions the adverse dental decision and specifies in writing the basis of the disagreement with the adverse dental decision, the third party administrator within 30 days shall: (a) designate a reviewing dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and (b) notify the treating dentist in writing promptly of the name and business address where the reviewing dentist can be contacted and telephone number which can be used to contact the reviewing dentist; (3) if an agreement is not reached within a reasonable period of time, not to exceed 30 days from the third party administrator's notice issued pursuant to subparagraph (b) of paragraph (2) of this subsection, the third party administrator shall make its decision and communicate the results of the reviewing dentist's dental decision to the treating dentist. b. Within 14 days of a written request by the treating dentist, or the patient or the patient's authorized representative, for the basis of an adverse dental decision by a reviewing dentist, provided to the treating dentist pursuant to paragraph (3) of subsection a. of this section, the third party administrator shall send a written notice containing the full name, address and telephone number of the reviewing dentist and a narrative statement specifically identifying the basis for the decision. L.2007, c.259, s.3.
NJ Rev Stat § 17:48G-4 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-4 - Inapplicability of act relative to certain decisions of insurers, third party administrators.

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 insurance coverage, that does not involve the making of a dental decision;  b. To regulate insurers' or third party administrators' use of a protocol for denying or limiting benefit payments for dental services where the protocol: (1) has been approved for use by a dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and (2) does not involve evaluation of an individual patient's dental care or condition; or  c. To regulate the application of contract limitations and exclusions, the credentialing of dentists or the conduct of retrospective fraud reviews. L.2007, c.259, s.7.
NJ Rev Stat § 17:48G-5 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-5 - Applicability of act to dental decisions.

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.
NJ Rev Stat § 17:48G-6 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48G-6 - Construction of act relative to board.

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 to regulate the conduct of an insurer or third party administrator.  L.2007, c.259, s.9.
NJ Rev Stat § 17:48H-2 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48H-2 - Certification, licensure, required

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. b. Any person, corporation, partnership, or other entity offering health care services to a carrier in a manner substantially provided for in this act shall be subject to the provisions of this act unless the entity is otherwise regulated under P.L.1973, c. 337 (C.26:2J-1 et seq.), Title 17 of the Revised Statutes, Title 17B of the New Jersey Statutes or P.L.1970, c.102 (C.18A:64G-1 et seq.). L.1999,c.409,s.2.
NJ Rev Stat § 17:48H-3 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48H-3 - Application for certification.

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 operate during the pendency of its application, but in no case longer than 12 months after the date of submission of the application to the Department of Banking and Insurance, unless the commissioner, by regulation, extends the 12-month limitation. In the event the application is denied, the applicant shall be treated as an organized delivery system whose certification has been revoked pursuant to sections 7 and 8 of this act.  Notwithstanding the obligations imposed by this act regarding certification requirements, nothing in this subsection shall operate to impair any contract in force on the effective date of this act, but this act shall apply to any contract renewed on or after the effective date of this act. b. The certification shall be valid for a period of three years. c. A certified organized delivery system shall not directly issue health benefits plans. L.1999, c.409, s.3; amended 2012, c.17, s.39.
NJ Rev Stat § 17:48H-5 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48H-5 - Review of application.

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 certification to an organized delivery system if the commissioner finds that the system meets the standards provided for in this act, including, but not limited to: (1) All of the material required by section 4 of this act has been filed; (2) The persons responsible for conducting the applicant's affairs are competent, trustworthy, and possess good reputations, and have had appropriate experience, training, and education; (3) The persons who are to perform the health care services are properly qualified; (4) The organized delivery system has demonstrated the ability to assure that health care services will be provided in a manner which will assure the availability and accessibility of the services; (5) The standard forms of provider agreements to be used by the organized delivery system are acceptable; and (6) The organized delivery system's contracts to provide services do not entail or will not result in the assumption of financial risk by the system. b. The commissioner may deny an application for certification if the applicant fails to meet any of the standards provided in this act or on any other reasonable grounds. If certification is denied, the commissioner shall notify the applicant and shall set forth the reasons for the denial in writing. The applicant may request a hearing by notice to the commissioner within 30 days of receiving the notice of denial. Upon such denial, the applicant shall submit to the commissioner a plan for bringing the organized delivery system into compliance or providing for the closing down of its business. L.1999, c.409, s.5; amended 2012, c.17, s.41.
NJ Rev Stat § 17:48H-6 (2021)
2021 New Jersey Revised Statutes|Title 17 - Corporations and Institutions for Finance and Insurance|Section 17:48H-6 - Notice of change, modification.

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 organized delivery system files with the commissioner, at least 60 days prior to use or adoption of the change, a notice of the change or modification, together with that information required by the commissioner to explain the change or modification. If the commissioner fails to affirmatively approve or disapprove the change or modification within 60 days of submission of the notice, the notice of modification shall be deemed approved. The commissioner may extend the 60-day review period for not more than 30 additional days by giving written notice of the extension before the expiration of the 60-day period. If a change or modification is disapproved, the commissioner shall notify the system in writing and specify the reason for the disapproval. b. Prior to entering into any contract with a carrier, a certified organized delivery system shall file with the commissioner, for the commissioner's approval, a copy of that contract. The filing shall be made no later than 60 days prior to the date that the contract is intended to be in effect. If the contract is not disapproved prior to the effective date by the commissioner, the contract shall be deemed approved. L.1999, c.409, s.6; amended 2012, c.17, s.42.