New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 23 - THIRD-PARTY ADMINISTRATORS › Subchapter 2 - LICENSE OR REGISTRATION REQUIREMENTS FOR THIRD-PARTY ADMINISTRATORS › Section 11:23-2.2 - Application filing requirements for licensure or registration of third-party administrators

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All third party administrators subject to licensure or registration shall obtain licensure or registration prior to operating in this State.
(b) Application for licensure or registration shall be made on a form prescribed by the Commissioner which can be found on the Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm
. The information that shall accompany the application shall include:
1. A copy of the applicant's basic organizational documents, which shall include articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement or other documents governing the operation of the applicant that are applicable to the applicant's form of business organization;
2. A copy of the executed bylaws, rules and regulations, or other documents relating to the operation of the applicant's internal affairs;
3. A biographical affidavit on the form provided on the Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm
or on the NAIC biographical affidavit form, which is incorporated by reference, as amended and supplemented, and which can be found on the NAIC website at
http://www.naic.org/documents/industry_ucaa_form11.pdf
, including the name, address, and official position of each person responsible for conducting the affairs of the applicant, including, but not limited to, if applicable: the members of the board of directors, executive committee, or other governing board or committee; the principal officers or partners; shareholders owning or having the right to acquire 10 percent or more of the voting securities of the corporation or partnership interest of a partnership, or equity interest, in the case of another form of business organization; or any person or entity who has loaned funds to the applicant for the operation of the business;
4. A statement of any criminal convictions or civil, enforcement or regulatory action, including actions relating to professional licenses, taken or pending against any of the persons who are responsible for the conduct of the affairs of the applicant or the applicant's affiliates, and the resolution of those actions and proceedings. If a license, certificate or other authority to operate has been refused, suspended or revoked by any jurisdiction, the applicant shall provide a copy of any orders, proceedings and determinations relating thereto;
5. A copy of the applicant's most recent financial statements audited by an independent certified public accountant. If the financial affairs of the applicant's parent company are audited by an independent certified public accountant, but those of the applicant are not, then a copy of the most recent audited financial statement of the applicant's parent company, audited by an independent certified public accountant, shall be submitted. An audited consolidated financial statement of the applicant and the parent company shall satisfy this requirement unless the Commissioner determines that additional or more recent information is required for the proper administration of the Act; and
6. A copy of the applicant's business plan, including:
i. A statement generally describing the applicant, its facilities, personnel, and the services to be offered by the third party administrator;
ii. Information on activities undertaken or to be undertaken in New Jersey;
iii. A statement of the applicant's capability for providing a sufficient number of experienced and qualified personnel in the areas of claims processing and recordkeeping, and information on staffing levels, including, but not limited to, training, hiring requirements, experience of staff;
iv. Evidence of establishment of a separate account for each benefits payer for payment of claims, with a description of the controls the applicant has put in place for it;
v. Evidence of a fidelity bond as required by 11:23-3.4;
vi. A description of the applicant's proposed method of marketing its services in New Jersey;
vii. A statement setting forth the means by which the applicant will be compensated;
viii. A description of the complaint and appeals procedures instituted by the applicant;
ix. A description of the quality assurance procedures established by the applicant;
x. Three-year projections of anticipated operating results. In addition, the business plan shall include a description of the assumptions used in the projections that shall include an explanation of each line item;
xi. A statement of the sources of working capital and any other sources of funding;
xii. A description of the provision for contingencies that will enable the applicant to perform the work for which it has contracted;
xiii. A list of the benefits payers under contract with the applicant, and a copy of the standard contract or contracts used by the applicant in the course of business. In the case of an applicant for registration, the information required to be filed with the Commissioner shall apply only to services provided to benefits payers other than an insurer;
xiv. A list of the subcontractors under contract with the applicant, and a copy of the standard contract or contracts used by the applicant in the course of business with subcontractors;
xv. A list of the reinsurers with whom the applicant does business and copies of the contract or contracts used by the applicant in the course of business with reinsurers;
xvi. A list of all administrative, civil or criminal actions and proceedings to which the applicant, or any of its affiliates have been subject and the resolution of those actions and proceedings. If a license, certificate or other authority to operate has been refused, suspended or revoked by any jurisdiction, the applicant shall provide a copy of any orders, proceedings and determinations relating thereto; and
xvii. A power of attorney, duly executed by the applicant, if not domiciled in this State, appointing the Commissioner and his or her successors in office as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the organization on a cause of action arising in this State may be served.