reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.4 - Termination and continuity of care standards for provider agreements with hospitals

Current through Register Vol. 56, No. 14, July 15, 2024
(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 termination.
1. If the reason(s) for which a provider may be terminated from the ODS' network is different from the reason(s) for which a provider may be removed from participation in a carrier's panel, the contract shall so specify this.
2. If the contract permits a provider to elect not to participate in a carrier's panel without also terminating the provider agreement with the ODS, the contract shall contain a provision setting forth the standards and procedures for this.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.5 - Additional standards applicable to contracts with primary care providers and specialists

Current through Register Vol. 56, No. 14, July 15, 2024
(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 obligation, if any, of the provider to acquire and maintain hospital admitting privileges.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.6 - Additional standards applicable to contracts with hospitals

Current through Register Vol. 56, No. 14, July 15, 2024
(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 shall be stated in the contract.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.7 - Third-party rights

Current through Register Vol. 56, No. 14, July 15, 2024
(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 not required for provider agreements between a carrier and an ODS (whose shareholders are composed solely of health care providers, if the ODS is certified or seeking certification solely for the provision of the performance of health care services by its shareholders).
(b) There shall be a provision in a provider agreement between a carrier and an ODS (whose shareholders are composed solely of health care providers, if the ODS is certified or seeking certification solely for the provision of the performance of health care services by its shareholders) specifying that the providers of the ODS that participate in the network of the carrier by virtue of the contract between the carrier and the ODS are third party beneficiaries 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.
(c) There shall be a provision in a provider agreement between a carrier and an ODS (whose shareholders are composed solely of health care providers, if the ODS is certified or seeking certification solely for the provision of the performance of health care services by its shareholders) that specifies that there is privity of contract between the carrier and each of the ODS' providers that participate in the carrier's network by virtue of the contract between the carrier and the ODS, and that the carrier shall have the right to enforce the terms of the contract against such providers in the event that the ODS fails to do so.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Appendix - APPENDIX › Exhibit 1

Current through Register Vol. 56, No. 14, July 15, 2024
Schedule of Fines
First offense
No documented harm: $ 250.00
Documented harm: $ 750.00
Subsequent offense
Less than 12 months from same prior offense:
No harm
Harm
. 2nd:
$ 750.00
$ 1,250
. 3rd:
$ 2,250
$ 2,750
. 4th:
$ 6,750
$ 7,250
. 5th+:
$ 10,000
$ 10,000
12 or more but less than 24 months from same prior offense:
No harm
Harm
. 2nd:
$ 625.00
$ 1,125
. 3rd:
$ 1,563
$ 2,063
. 4th:
$ 3,908
$ 4,408
. 5th:
$ 9,770
$ 10,000
. 6th+:
$ 10,000
$ 10,000
24 or more but less than 36 months from same prior offense:
No harm
Harm
. 2nd:
$ 500.00
$ 1,000
. 3rd:
$ 1,000
$ 1,500
. 4th:
$ 2,000
$ 2,500
. 5th:
$ 4,000
$ 4,500
. 6th:
$ 8,000
$ 8,500
. 7th+:
$ 10,000
$ 10,000
36 of more months from same prior offense:
No harm
Harm
. 2nd:
$ 375.00
$ 875.00
. 3rd:
$ 563.00
$ 1,063
. 4th:
$ 845.00
$ 1,345
. 5th:
$ 1,268
$ 1,768
. 6th:
$ 1,902
$ 2,402
. 7th:
$ 2,853
$ 3,253
. 8th:
$ 4,280
$ 4,780
. 9th:
$ 6,420
$ 6,920
. 10th:
$ 9,630
$ 10,000
. 11th:
$ 10,000
$ 10,000
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(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 to the authority set forth at 26:2S-7.1, to be accepted by all carriers offering managed care plans for the purpose of credentialing and recredentialing physicians who seek to participate in a carrier's provider network, including physicians employed by hospitals or other health care facilities.
(c) This subchapter establishes alternative, acceptable means by which carriers offering managed care plans may credential and recredential physicians.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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 business in accordance with 17B:17-1 et seq., a hospital service corporation authorized to do business pursuant to 17:48-1 et seq., a medical service corporation authorized to do business pursuant to 17:48A-1 et seq., a health service corporation authorized to do business pursuant to 17:48E-1 et seq., or a health maintenance organization authorized to transact business pursuant to 26:2J-1 et seq.
"Credentialing" means the process of collecting and validating the professional qualifications of a physician and evaluating those qualifications against a carrier's standards of qualifications for participation in the carrier's health care provider network for the carrier's managed care plans.
"Credentials data" means information, attachments, or answers to questions required by a carrier to complete the credentialing or recredentialing of a physician.
"Department" means the Department of Banking and Insurance.
"Managed care plan" means a health benefits plan (as health benefits plan is defined at 26:2S-1 et seq.), that integrates the financing and delivery of appropriate health care services to covered persons by arrangement with participating providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating providers and procedures provided for in the plan.
"New Jersey Universal Physician Application" means the form developed by the Department and set forth in the Appendix to this subchapter as Exhibit 1.
"New Jersey Physician Recredentialing Application" means the form developed by the Department and set forth in the Appendix to this subchapter as Exhibit 2.
"Physician" means a person who is licensed by the State Board of Medical Examiners in accordance with the provisions of Title 45 of the Revised Statutes.
"Prepopulate" means to pre-print requested information derived from a database on a form prior to distributing the document to the target population for review, completion and correction, as appropriate.
"Recredentialing" means the process by which a physician's information related to his or her credentials is updated and re-verified for purposes of determining whether the physician shall continue to participate in the carrier's health care provider network.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.3 - Credentialing standards

Current through Register Vol. 56, No. 14, July 15, 2024
(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 carrier's receipt of notice from CAQH of an applicant's credentialing application, a carrier shall notify the applicant whether the application is complete or incomplete. If the application contained an e-mail address, the carrier may provide the notice electronically. If the application did not contain an e-mail address, the carrier shall provide the notice in writing. If an application is incomplete, the notice shall identify all deficiencies and specify all additional information required to be submitted by third parties and, if applicable, by the applicant in order for the application to be considered complete. The notice shall also specify the due date for receipt of any additional information required from the applicant.
2. The notice referenced in (a)1 above shall include the phone number and e-mail address of the carrier's department responsible for accepting the information required to complete the application and for providing assistance regarding the carrier's credentialing process and the status of a credentialing application. Carriers shall respond to all credentialing inquiries within five business days.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.4 - Recredentialing standards

Current through Register Vol. 56, No. 14, July 15, 2024
(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 participate in the carrier's network(s).
(b) A carrier that offers managed care plans may continue to use another physician recredentialing application form for renewal of credentialing if the carrier prepopulates the form with the individual information of each physician to whom the form is sent.
1. Carriers electing to use a prepopulated recredentialing application shall inform physicians of the availability of the New Jersey Physician Recredentialing Application, downloadable through the Department's website
www.state.nj.us/dobi
or indicate where physicians may obtain a hard copy of the New Jersey Physician Recredentialing Application.
i. When a physician makes an oral inquiry concerning a recredentialing application, then the carrier's response concerning the availability of the New Jersey Physician Recredentialing Application may be oral; however, any mailing of the carrier's recredentialing application form as a follow-up to the oral request shall include a written notice referencing the availability of the New Jersey Physician Recredentialing Application, and information on how to access the application.
ii. When a physician inquires in writing concerning a recredentialing application, then the carrier shall include with its recredentialing application form a written notice referencing the availability of the New Jersey Physician Recredentialing Application, and information on how to access the application.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.5 - Right to request additional information

Current through Register Vol. 56, No. 14, July 15, 2024
(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 shall not be construed to restrict the right of a carrier to request additional information necessary for credentialing or recredentialing.
1. Notwithstanding (a) above, a carrier shall not request information that duplicates information already requested on the New Jersey Universal Physician Application form, or as part of the national credentialing database, data bank or repository of health care providers.
2. A request by a carrier or other qualified entity for primary or secondary source verification shall not be considered a request for duplicative information, or otherwise prohibited.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Section 11:24C-1.6 - Enforcement

Current through Register Vol. 56, No. 14, July 15, 2024
(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 26:2S-16; and/or
2. Other remedies for violations of statutes, as provided by State and Federal law.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 1 - PHYSICIAN CREDENTIALING › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
EXHIBIT 1
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EXHIBIT 2
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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(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 treatment services for bleeding episodes associated with hemophilia.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.3 - Carriers responsibility to use designated health care providers for home treatments

Current through Register Vol. 56, No. 14, July 15, 2024
(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 more in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least two designated health care providers, unless there are fewer than two designated health care providers designated in New Jersey, in which event, the carrier shall arrange for the provision of home treatment services with the lone designated health care provider, regardless of the carrier's enrollment.
(c) Carriers with aggregate enrollment of fewer than 50,000 covered persons in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least one designated health care provider.
(d) Nothing in this subchapter shall be construed to limit or eliminate any carrier's obligation to credential and re-credential health care providers with which the carrier arranges for the provision of home treatment of hemophilia with respect to such treatments or any other services that the health care provider may render to a carrier's covered persons.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.4 - Application: procedure to become a designated health care provider of home treatment services

Current through Register Vol. 56, No. 14, July 15, 2024
(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
Office of Managed Care
Attention: Hemophilia Treatment Designation Application
PO Box 329
Trenton, NJ 08625-0329
Overnight Services (UPS, FedEx, Airborne):
NJ Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
Attention: Hemophilia Treatment Designation Application
20 West State Street
9th Floor
Trenton, NJ 08625-0329
(b) The applicant shall comply with the "Instructions and Checklist" set forth in the Appendix to this subchapter, incorporated herein by reference, when submitting the application.
(c) Applicants may submit copies of the application in paper or electronic format, or both, subject to the requirement that at least one copy of the application be in paper format, and that the original and copy(ies) be set forth in the same order and contain the same content.
(d) The applicant shall submit a response to each of the requirements set forth in 11:24C-2.5.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.5 - Application: demonstration of qualifications for becoming a designated health care provider of home treatment services

Current through Register Vol. 56, No. 14, July 15, 2024
(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 licenses, registrations and permits.
(b) The applicant shall demonstrate each of the following:
1. Its ability to provide services and to maintain and provide all brands of blood product, including low, medium and high-assay range levels to execute treatment regiments as prescribed by a covered person's attending physician, without making substitutions of blood products except upon prior approval of the attending physician;
2. Its ability to maintain and provide all needed ancillary supplies for the treatment or prevention of bleeding episodes, including blood infusion equipment and cold compression packs;
3. Its ability to deliver any and all prescribed blood products, medications, nursing services and blood infusion equipment within three hours after receipt of a prescription for a covered person's emergent situation, 24-hours per day, seven days per week;
4. Its experience in management of bleeding disorders;
i. Experience may be demonstrated by performance of services in other states;
ii. Experience shall include, at a minimum, the provision of services for the home treatment of hemophilia;
5. Its ability to perform appropriate recordkeeping and maintain appropriate records, consistent with the medical and health record standards for home health agencies at N.J.A.C. 8:42;
6. Its ability to monitor and actively participate in product recall and notification systems, both drug-related and otherwise;
7. Its ability to assist covered persons in obtaining third party reimbursements when necessary or appropriate;
8. Its ability to comply with proper removal and disposal of hazardous waste, in accordance with the standards applicable to home health agencies at N.J.A.C. 8:42;
9. That it has written policies and procedures regarding the discontinuation of services when an individual is no longer able to pay for or assure payment of the costs associated with the services rendered by the applicant;
i. The applicant shall submit its written policies and procedures to the Department;
ii. The applicant's written policies and procedures shall address the issue of dissemination of the policies and procedures to covered persons upon request;
10. Its ability to disseminate information to covered persons regarding probable costs for services that the applicant may provide that are not covered by a covered person's health benefits plan; and
11. Its program for credentialing and recredentialing the health care practitioners or other health care providers contracted with or employed by the applicant.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.6 - Application: process for incomplete applications

Current through Register Vol. 56, No. 14, July 15, 2024
(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 is incomplete, and shall return all documentation and electronic files submitted with the incomplete applications to the applicant.
(c) Within 45 days after the Department sends notice to the applicant that the application is incomplete, an applicant may resubmit the application with the information necessary to make the application complete. The Department shall not consider perfected applications outside of the specified 45-day time frame, nor shall the Department retain the perfected application.
1. The Department shall return the application to the applicant only if the resubmitted application includes prepaid return mail packaging.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.7 - Application: complete applications and additional information

Current through Register Vol. 56, No. 14, July 15, 2024
(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 additional information received from the applicant or from other sources if the Department believes the information is relevant to the Department's review of the application, notwithstanding a determination that the application is complete.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.8 - Department review: minimum standards for designation

Current through Register Vol. 56, No. 14, July 15, 2024
(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 13:39-4.1 6.
1. With respect to the applicant's pharmacy permit, at least some portion of the applicant's pharmacy services shall be dedicated to the provision of services and supplies specifically for the treatment of hemophilia.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.9 - Annual report

Current through Register Vol. 56, No. 14, July 15, 2024
(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. Proof of all required licenses and certifications needed to conduct business in the State of New Jersey, including waste disposal contracts;
3. Proof of inventory available that will also verify access to all products, assays and contractual agreements with pertinent manufacturers and/or distributors;
4. Information demonstrating the provider's nursing expertise in servicing these patients;
5. Patient intake, evaluation and follow-up policies and procedures, including initial information on fee/reimbursement structure and emergency delivery procedures; and
6. All insurance reimbursement, billing and assistance procedures.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.10 - Loss of designation as a home treatment provider

Current through Register Vol. 56, No. 14, July 15, 2024
(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 health care providers;
3. Revocation, suspension or surrender of a pharmacy permit, including a specialized permit, unless the specialized permit was surrendered in order to be replaced by another form of pharmacy permit;
4. Failure of the health care provider to meet one of the standards on which designation was originally issued, other than maintenance by the health care provider and/or its subcontractors of registration(s), license(s) or permit(s) in good standing; or
5. Failure of a designated health care provider to report material changes in accordance with 11:24C-2.1 2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.11 - Cessation of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When loss of designation results from a situation set forth at 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 carrier to arrange for another designated health care provider, whether or not in the carrier's network, to provide services to covered persons, prior to withdrawal of any nursing services or supplies from the home of any covered person.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.12 - Obligation of designated health care provider to notify Department of material changes

Current through Register Vol. 56, No. 14, July 15, 2024
(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 report changes in writing at least 30 days prior to the expected date of change, or within no more than 10 days following the date of a change that was unexpected.
2. In providing notice of a change, expected or unexpected, a health care provider shall specify what action it plans to take to assure that it remains in compliance or comes back into compliance with the standards for designation.
i. With respect to providing information regarding a plan to bring the health care provider back into compliance with the standards for designation, the plan shall be structured to assure that the health care provider is in compliance within no more than 45 days following the material change.
3. If the plan of correction is acceptable and implemented, no loss of designation will occur, except when the material change is revocation or surrender of a license, permit or registration, or a suspension that cannot be remedied in 45 days.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 2 - DESIGNATION OF HEMOPHILIA HEALTH CARE PROVIDERS › Section 11:24C-2.13 - Designation list

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall maintain a written list of designated home treatment health care providers, which shall be made available to any person upon request made to the Department, and shall be maintained on the Department's Internet site.
(b) The list for general distribution, whether in paper or electronic format, shall be updated as frequently as necessary, but shall be published as a public notice in the New Jersey Register no more frequently than annually.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.1 - Scope and applicability

Current through Register Vol. 56, No. 14, July 15, 2024
(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 not have a direct bearing on the relationship between a carrier and a health care provider for the provision of any other services or supplies.
(c) Nothing in this subchapter shall be construed to limit the obligation of any carrier to comply with other laws regarding the provision of benefits or services for the treatment of hemophilia.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.3 - Carrier' obligation to provide benefits or services for the home treatment of bleeding episodes associated with hemophilia

Current through Register Vol. 56, No. 14, July 15, 2024
(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 with hemophilia unless that person shall be a designated provider of such services, nor shall a carrier refer any covered person or cause a covered person to be referred to a person that is not a designated health care provider of services and supplies for the home treatment of bleeding episodes associated with hemophilia.
(c) Carriers with an aggregate enrollment of 50,000 covered persons or more in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least two designated health care providers, unless there are fewer than two designated health care providers designated in New Jersey, in which event, the carrier shall arrange for the provision of home treatment services with the lone designated health care provider, regardless of the carrier's enrollment.
(d) Carriers with aggregate enrollment of fewer than 50,000 covered persons in managed care plans shall arrange for the provision of home treatment of bleeding episodes associated with hemophilia with at least one designated health care provider.
(e) Nothing in this subchapter shall be construed to limit the obligation of a carrier to provide out-of-network benefits for home treatment services accessed at the option of the covered person through a health care provider that is not designated, when the managed care plan has an out-of-network benefits component.
(f) Nothing in this subchapter shall be construed to limit the obligation of a carrier to provide benefits or services on an in-network basis when a covered person accesses home treatment services from a health care provider, designated or not, because the carrier fails to have an agreement with a designated health care provider to provide services for the home treatment of bleeding episodes associated with hemophilia to the covered person at the time that such services are prescribed.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.4 - Loss of designated status

Current through Register Vol. 56, No. 14, July 15, 2024
(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 services and supplies of that health care provider for home treatment of bleeding episodes associated with hemophilia.
(b) With respect to covered persons that have been receiving services and supplies from a health care provider that has lost its designation, the carrier shall continue to provide services or benefits to or on behalf of the covered person at an in-network level for home treatment services and supplies, until such time as arrangements are made for the covered person to receive home treatment services and supplies from another in-network designated health care provider, or for four months following the date of the loss of designation, whichever occurs first.
1. Notwithstanding (b) above, the carrier shall not be required to continue to provide services or benefits to a covered person at an in-network level when the health care provider's loss of designation is the result of revocation or surrender of a license, permit or registration, or is the result of a suspension of a license, permit or registration that cannot be corrected by reinstatement within 45 days following the date of the suspension, except as may be necessary for the carrier and health care provider to transition the covered person's care to another designated health care provider, consistent with 11:24C-2.1 1(a).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.5 - Termination of the agreement for services and supplies for home treatment of bleeding episodes associated with hemophilia

Current through Register Vol. 56, No. 14, July 15, 2024
(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 carrier shall continue to provide services or benefits to or on behalf of a covered person at an in-network level until the end of four months following the date of termination, or until arrangements are made for the covered person to obtain home treatment services and supplies from another in-network designated health care provider, whichever occurs first.
(b) The requirements of (a) above shall not apply when the agreement terminates on the basis of breach, fraud, or a determination by the carrier's medical director that the health care provider is an imminent danger to one or more covered persons, whether such breach, fraud or imminent harm is related to the provision of services or supplies for home treatment of bleeding episodes associated with hemophilia, or other services and supplies for which the carrier and health care provider have an agreement.
1. The carrier shall arrange to pay for services through another designated health care provider.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.6 - List of designated home treatment health care providers and State-recognized outpatient regional hemophilia care centers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall maintain and make available a list of designated health care providers in accordance with 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 designated health care providers, nothing in this subchapter shall be construed to limit a carrier's responsibility to assure that a health care provider is designated and remains designated while providing services and supplies to covered persons for the home treatment of bleeding episodes associated with hemophilia.
(c) Nothing in this subchapter shall be construed to limit or eliminate any carrier's obligation to credential and recredential health care providers with which the carrier arranges for the provision of home treatment of hemophilia with respect to such treatments or any other services that the health care provider may render to a carrier's covered persons.
(d) The Department adopts and incorporates herein the standards and procedures used by the United States Department of Health and Human Services to designate regional hemophilia treatment centers in accordance with Federal laws.
1. Information regarding the Federally funded regional hemophilia centers (and grants therefor) may be obtained by contacting the Maternal and Child Health Bureau of the Health Resources and Services Administration within the United States Department of Health and Human Services, or a list of hemophilia treatment centers by state currently is available through the Centers for Disease Control at
http://www.cdc.gov/ncbddd/hemophilia/HTC.html
.
2. In the event that there is any discrepancy between the Department-generated list of State-recognized outpatient regional hemophilia care centers and the hemophilia treatment centers included in the United States Department of Health and Human Service's regional network(s) for the State of New Jersey, the information provided by the United States Department of Health and Human Services shall take precedence.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.7 - Clinical laboratories at State-recognized outpatient regional hemophilia care centers

Current through Register Vol. 56, No. 14, July 15, 2024
(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 laboratory techniques, and the carrier does not have an agreement for the provision of services at any clinical laboratory of a State-recognized outpatient regional hemophilia care center, the carrier shall approve the use of such services at the clinical laboratory of a State-recognized outpatient regional hemophilia care center determined appropriate by the attending physician.
1. The center shall provide services or benefits to or on behalf of the covered person as if the covered person had accessed services in-network when the services are accessed in accordance with (a)1 above.
2. A refusal by a carrier or its agent to provide benefits or services as if in-network under the circumstances set forth in (a)1 above shall be considered a utilization management denial, and subject to the utilization management appeal process set forth at N.J.A.C. 11:24-8 or 11:24A-4.1 2, as appropriate to the type of carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.8 - Effect of Bulletin OMC 2001-04

Current through Register Vol. 56, No. 14, July 15, 2024
(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 covered persons to such health care providers, and the carrier shall be considered in compliance with these rules until whichever of the following occurs first:
1. The Department makes a determination and provides written notice to the person that the person does not meet the standards for designation, if the person files an application for designation in accordance with 11:24C-2.4;
2. The person loses designation pursuant to 11:24C-2.1 0; or
3. The carrier and person otherwise terminate their agreement, or amend one or more terms thereof, with respect to the provision of services for home treatment of bleeding episodes associated with hemophilia.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 3 - BENEFITS OR COVERAGE OF SERVICE FOR HEMOPHILIA TREATMENT › Section 11:24C-3.10 - Violations

Current through Register Vol. 56, No. 14, July 15, 2024
A carrier that violates any provisions of this subchapter shall be subject to fines and other penalties available pursuant to 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 referral to designated health care providers if there are no designated health care providers in New Jersey on the date that services for the home treatment of bleeding episodes related to hemophilia are sought by or for a covered person.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(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 corporations, and health maintenance organizations (HMOs) authorized to issue health benefits plans in this State and to organized delivery systems (ODSs). This subchapter shall not apply to those contracts entered into between a carrier and Medicaid to provide Medicaid Only coverage or NJ FamilyCare coverage.
(c) On and after January 1, 2014, this subchapter shall apply to all newly entered agreements and all renewals of previously existing agreements.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.3 - Provider agreements

Current through Register Vol. 56, No. 14, July 15, 2024
(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 Department with the HMO's initial application for a certificate of authority pursuant to 26:2J-3 shall be subject to prior approval by the Commissioner.
(b) For provider agreements for which fees are not individually negotiated, carriers shall make available to network providers and prospective network providers all complete fee schedule(s) that are or are to be included in their agreement. Fee schedules shall be supplied in writing unless the carrier makes the fees for included CPT or HCPCS codes available on their website or otherwise makes them available electronically to providers.
1. When a provider is contemplating participating in multiple health benefits plans offered by a carrier and such plans have different fee schedules, the carrier shall provide the complete proposed fee schedule(s) applicable to that provider for each plan in which the provider participates or plans to participate.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.4 - Provider reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
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 included in and excluded from the alternate reimbursement methodology.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.5 - Content and availability of provider network directories

Current through Register Vol. 56, No. 14, July 15, 2024
(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 on all participating providers: name, gender, office locations, phone numbers, professional designation, specialty, acceptance of new patients, practice limitations, and languages spoken other than English.
(c) Directories shall contain a listing of the carrier's in-network hospital outpatient facilities by the types of services the facilities provide. Where applicable, directories shall also prominently display a statement advising members that not all outpatient service providers located at in-network hospitals are in-network providers, and urging members to confirm whether an outpatient service provider is or is not a member of the network before obtaining services from such provider.
(d) A carrier's electronic directory shall include functions designed to facilitate the ability of members to customize their search for providers. Search functions shall include, but not be limited to, specialty and geographic area.
(e) Upon request, carriers shall provide their current printed directory to members and prospective members of the health benefits plans offered by the carrier. The requirement to supply printed directories upon request may be complied with by printing and mailing the most current version of the on-line directory applicable to a particular member's plan in lieu of periodic publication and stocking of hard copy directories. The carrier shall mail a copy of the printed directory to a member or prospective member within five business days of the request measured from the date of the carrier's receipt of the request.
(f) If a carrier publishes a hard copy of the directory, the information shall accurately reflect the content of the carrier's electronic directory as of the date the printed directory was submitted for publication. The following information shall be included in or accompany the printed directory:
1. The date of publication of the printed directory;
2. A statement that the directory is accurate as of the date on which the printed directory was submitted for publication;
3. A statement that more current directory information is available on the carrier's electronic directory available on the carrier's website;
4. The anticipated date on which the next printed edition will be published; and
5. The carrier's website address where the electronic directory can be accessed.