reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 5 - INDEPENDENT HEALTH CARE APPEALS PROGRAM › Section 11:24A-5.1 - General requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall be responsible for the operation of the Independent Health Care Appeals Program.
1. The Department shall combine the Independent Health Care Appeals Program with the External Appeals program set forth under N.J.A.C. 11:24-8.7, but, in accordance with the Administrative Procedures Act, 52:14B-1 et seq., may amend the standards set forth at 11:24-8.7 as necessary to make the appeal process more effective for covered persons insured through contracts or policies of carriers that are not HMOs.
2. The general qualifications of and standards of practice for IUROs participating in the Independent Health Care Appeals Program are set forth at 11:24-8.8.
3. The Department shall establish a per case reimbursement schedule for all IUROs that participate in the Independent Health Care Appeals Program, based on the bids obtained by IUROs.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 5 - INDEPENDENT HEALTH CARE APPEALS PROGRAM › Section 11:24A-5.2 - Department review of carrier actions on IURO recommendations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall periodically review records of carrier reports submitted pursuant to 11:24A-3.7 to determine whether a carrier exhibits a pattern of noncompliance with the recommendations of an IURO as well as possible violations of patient rights or other applicable laws.
(b) If the Department determines that a carrier exhibits a pattern of noncompliance with the recommendations of an IURO, the Department shall review:
1. Whether the carrier's noncompliance is with a specific set of recommendations;
2. Whether the carrier's noncompliance is with a specific IURO (in the event more than one IURO participates in the Independent Health Care Appeals Program); and
3. The carrier's utilization management program, if any.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 5 - INDEPENDENT HEALTH CARE APPEALS PROGRAM › Section 11:24A-5.3 - Notice requirement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 26:2S-14.1 and 45:9-22.2 6 and applicable rules of the Department of Health and the Board of Medical Examiners, respectively, all general hospitals licensed pursuant to 26:2H-12 et seq. and all physicians licensed pursuant to N.J.A.C. 13:35 are required to post in all patient waiting rooms within the hospital or the physicians medical office a notice providing information about, and how to apply for, the Independent Health Care Appeals Program (IHCAP) established pursuant to 26:2S-11. In accordance with 26:2S-14.2, the size, content, and format of the notice shall be as set forth in (b) below.
(b) The notice shall be in the format and include the content as set forth in the notice entitled "An Explanation of an Individuals Right to Appeal Health Insurance Determinations," incorporated herein as the subchapter Appendix, and also posted on the Departments website at
www.dobi.nj.gov/ihcapappeals/
. If posted using multiple pages, each page of the notice shall be at least 8 1/2 x 11 inches with print in 12-point type or larger. If displayed as a one-page poster, the poster shall be of sufficient size to depict all of the required text of the notice in print of at least 12-point type.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS › Subchapter 5 - INDEPENDENT HEALTH CARE APPEALS PROGRAM › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter shall apply to all organized delivery systems required by the Act to become a certified organized delivery system, and to all organized delivery systems required by the Act to become licensed, except where the language of the chapter clearly indicates otherwise. A non-exhaustive list of examples of entities that are subject to this chapter is set forth in Exhibit 9 of the Appendix to this chapter, incorporated herein by reference.
(b) This chapter shall apply to all carriers offering health benefits plans, except where the language of the chapter clearly indicates otherwise.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.3 - CODS: compliance time frames

Current through Register Vol. 56, No. 14, July 15, 2024
No ODS required to become a CODS in accordance with 11:24B-2.1 shall execute or renew a contract with a carrier as a CODS unless the ODS has filed a complete application for certification in accordance with the requirements of this chapter, and the application has been approved by the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.4 - CODS: suspension or revocation of a certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department may suspend or revoke the certification of a CODS upon a finding that:
1. The ODS is operating in contravention of its basic organizational documents;
2. The ODS is unable to fulfill its obligations to the carriers with which it has contracted;
3. The continued operation of the ODS would be detrimental to the carriers with which it has contracted to provide services, or hazardous to the health and welfare of the covered persons of the carriers with which the ODS has contracted to provide services;
4. The ODS is unable to maintain the standards applicable to it in this chapter;
5. The ODS has failed to comply with the applicable provisions of 26:2S-1 et seq., and rules promulgated pursuant thereto;
6. The ODS has failed to provide the services for which it was certified and has provided services in contravention of the contract or contracts filed with the Department, or the ODS has provided services pursuant to management agreements or provider agreements for which the ODS has not been approved;
7. The ODS has failed to comply with the Act, or with other applicable law not otherwise enumerated in (a)1 through 6 above; or
8. There are other grounds that the Department believes reasonably warrant suspension or revocation of the certification.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.5 - LODS: recommendation to suspend or revoke a license

Current through Register Vol. 56, No. 14, July 15, 2024
The Department may suspend or revoke the license of an LODS for the reasons set forth at 11:24B-1.4(a).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.6 - CODS: penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department may assess a penalty of not less than $ 250.00 nor more than $ 10,000 against a CODS for each day that the CODS is in violation of the Act or rules promulgated pursuant thereto, in lieu of, or in addition to, suspension or revocation of a certification.
(b) The Department shall not assess a penalty without providing written notice of the penalty, specifying the reasons therefor, and providing the ODS an opportunity to request a hearing pursuant to the Administrative Procedure Act, 52:14B-1 et seq., and the Uniform Administrative Hearing Rules, N.J.A.C. 1:1.
1. The Department may, upon the request of the ODS, postpone the effective date of the penalty pending the request for a hearing, or until the final decision forthcoming from the hearing.
2. If an ODS requests a hearing, the ODS shall set forth in its request for a hearing all factual and legal bases upon which the ODS disputes the findings set forth in the notice of penalty assessment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.7 - CODS: confidentiality of information regarding covered persons

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A CODS shall maintain confidentially any data or information relating to the diagnosis, treatment, or health of a carrier's covered persons, or prospective covered persons, obtained from the carrier, a provider, or from the individual, and shall not disclose such information to any person except:
1. To the extent it may be necessary to carry out the purposes of the Act or this chapter, including investigation of complaints by a carrier, the Department, and adjudication of claims or other reimbursement by a carrier or its agent;
2. Upon the express consent of the covered person or prospective covered person, or his or her legal representative, if the covered person or prospective covered person is incapacitated or a minor;
3. Pursuant to statute or court order for the production of evidence or the discovery thereof;
4. In the event of a claim or litigation between a covered person or prospective covered person and the CODS or carrier wherein the data or information is relevant to the claim or litigation. A CODS shall be entitled to claim any statutory privilege against disclosure that a provider or carrier that furnished the information to the CODS is entitled to claim;
5. For epidemiological and outcomes research when the identity of the covered person, prospective covered person, or contract holder is protected through the use of anonymized information, as defined at N.J.S.A. 17:48H-30e; or
6. Upon the informed consent of the covered person, prospective covered person, or contract holder (but only when the contract holder is a natural person, and is providing consent solely on his or her own behalf), which consent has been obtained for research approved by an institutional review board in accordance with Federal requirements for informed consent pursuant to 21 CFR Part 50 or 45 CFR Part 46.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.8 - ODS: confidentiality of submitted information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall maintain personal information contained in biographical affidavits confidentially to prevent violation of citizens' reasonable expectations of privacy in accordance with 47:1A-1. For purposes of this chapter, an affiant's name shall not be considered personal information that is confidential.
(b) The Department shall maintain confidentially documents that are not government records, as that term is defined at N.J.S.A. 47:1A-2 of the Open Public Records Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 1 - GENERAL PROVISIONS › Section 11:24B-1.9 - Carriers: contracts with organized delivery systems

Current through Register Vol. 56, No. 14, July 15, 2024
No ODS shall maintain contracts, either directly or indirectly, with a carrier with respect to a health benefits plan for the performance of provision of services set forth at 11:24B-2.4(a)  unless the ODS is certified or licensed by the Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.1 - CODS: who must file for certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The obligation to submit an application for certification arises when a person otherwise meeting the definition of an ODS elects to enter into contracts with one or more carriers directly, rather than solely contracting with carriers through another ODS, and the ODS assumes no financial risk under the rules adopted by the Department at N.J.A.C. 11:22-3, or ceases to assume a financial risk under the rules at N.J.A.C. 11:22-4.
(b) The obligation to submit an application for certification arises when an ODS assuming financial risk is granted an exemption by the Department from the licensing requirement in accordance with N.J.A.C. 11:22-4.
(c) Notwithstanding (a) above, a person otherwise meeting the definition of an ODS shall not be obligated to obtain certification if:
1. The person contracts with one or more carriers directly solely for the provision of health care services that will be performed by only the health care professionals that are shareholders or employees of the ODS, within the scope of the health care professionals' individual licenses;
2. The person is a carrier regulated under Title 17 of the Revised Statutes, Title 17B of the New Jersey Statutes, or 26:2J-1 et seq., and amendments thereto;
3. The person is regulated by 18A:64G-1 et seq. (Medical and Dental Education Act of 1970, establishing the University of Medicine and Dentistry of New Jersey);
4. The person solely provides or arranges to provide pharmaceutical services;
5. The person solely provides or arranges to provide case management services;
6. The person solely provides employee assistance plans; or
7. The person provides the services set forth at 11:24B-2.4(a)3  through 9, but does not also provide the services set forth at 11:24B-2.4(a)1  or 2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.2 - CODS: general filing instructions for applications for certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) CODS shall file applications for certification with the Department at the following address:
Attn: ODS Certification
New Jersey Department of Banking and Insurance
Market Regulation
PO Box 329
Trenton, NJ 08625-0329
(b) The CODS shall submit an application for certification no less than 90 days prior to the date that the CODS intends to execute its first contract with a carrier.
(c) The CODS shall submit an application in a paper format subject to the following conditions:
1. CODS shall submit applications in three-ring binders, labeled with the CODS' name, and numbered if more than one binder is required for the submission, with an indication of how many total binders in the series there are (for example: 1 of 2 and 2 of 2);
2. A CODS shall clearly tab and segregate exhibits, presenting exhibits in the order in which the information requested is set forth at 11:24B-2.3 and 2.4;
3. With pages numbered;
4. With every specimen contract form generated by the CODS or by a carrier with which the CODS has contracted or intends to contract containing a unique identifier in the lower left corner of each page of the form;
5. With a completed Application Checklist, set forth as Exhibit 2 of the Appendix to this chapter and incorporated herein by reference, set forth as part of the cover to the application; and
6. With a check or money order made payable to the Treasurer, State of New Jersey, in the amount set forth at 11:24B-2.9.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.4 - CODS: Part B of the application for certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An ODS shall specify the services it will deliver on behalf of one or more carriers under contract, by category, as follows:
1. Performing or arranging for the performance of one or more types of health care services;
2. Network management, including recruitment and retention;
3. Credentialing and recredentialing;
4. Utilization management development;
5. Utilization management application;
6. Utilization management appeals;
7. Member complaints;
8. Provider complaints; and
9. Continuous quality improvement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.6 - CODS: modification of certification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A CODS shall submit an application to modify its certification when:
1. There is to be a change in control of the ODS, the ODS' parent, or an affiliate of an ODS that has control over the ODS; or
2. The ODS wants to alter the categories of services on which its current certification is based.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.7 - CODS: notice of changes to certification information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as set forth in 11:24B-2.6, an ODS shall provide the Department with 30 days prior notice of changes to information contained in its certification unless 30 days' prior notice was impossible, in which event, the ODS shall provide notice of the change as soon as possible, but within no more than 30 days following the date of the change.
1. Notwithstanding (a) above, notice is not required with respect to changes that correct clerical errors, or which are of an administrative nature that has no impact upon the performance or arrangement for the performance of health care services for which the ODS has been certified, or which may have an impact upon the performance of health care services, but does not have an adverse impact upon the ODS' network adequacy.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.8 - Annual report and renewal

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The certification of an ODS shall expire three years after issuance. A certification shall automatically renew for another three-year period unless the Department finds that the ODS no longer complies with the Act or other applicable law, or if the ODS fails to file a complete annual report and information set forth in this section.
(b) An ODS shall file an annual report with the Department no later than March 1 of each year for the year ended December 31 immediately preceding on the form prescribed by the Department which can be found on the Department's website:
www.state.nj.us/dobi/formlist.htm
. The information required shall include:
1. The total number of provider and member complaints filed within the year being reported upon, categorized by type of complaint;
2. The total number of utilization management requests for authorization and the total number of denials;
3. The total number of utilization management appeals filed and the outcome of such appeals; and
4. The total number of claims paid, the total number of claim appeals filed and processed, and the resolution of such appeals.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 2 - CERTIFICATION AND REVIEW OF LICENSE APPLICATIONS › Section 11:24B-2.10 - Review of applications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall determine whether an application is disapproved as incomplete within 30 days of the date of receipt of the application, and shall notify the ODS in writing of a determination of incompleteness, specifying the items that the ODS shall submit in order to make the application complete.
1. With respect to an application for certification or an application for certification modification, the ODS may resubmit the application with the required information, annotating it as a "Resubmission following Notice of Incompleteness" without submission of any additional application fee within no more than 120 days following notice of disapproval, and the review of the application shall remain active; however, the Department shall treat resubmission of an application at a later date as an entirely new submission, requiring submission of a new application fee, as appropriate to the type of application in question.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.1 - Carriers and CODS: mutual obligation to comply fully with certain standards

Current through Register Vol. 56, No. 14, July 15, 2024
A carrier's delegation to an ODS of performance of a legal obligation of the carrier established by statute or regulation shall not relieve the carrier of its legal obligation to assure that performance of that obligation occurs consistent with standards established by law, nor shall the delegation be construed to prevent the Department from taking action against the carrier to enforce performance of the obligation, or for failure to assure appropriate performance of the obligation, notwithstanding that the Department may also take action against the ODS.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.2 - Carriers: limitations on delegation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall only delegate the performance of those functions set forth at 11:24B-2.4(a), as further described in this subchapter, to a CODS certified for those functions.
(b) A carrier may contract with an entity to perform less than a majority of the duties specified for a function as set forth within this subchapter, in which event, the entity performing those specific duties need not be certified to perform the function in order to contract with the carrier, and the carrier will not be considered to have delegated that function in accordance with this chapter.
1. Nothing in (b) above shall be construed to relieve the carrier from complying with any requirements of other laws that may require notice of delegation of major functions or submission of contracts by carriers to the Department, including N.J.A.C. 11:24, or 11:24A or N.J.A.C. 11:4-37 or 11:22-5.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.3 - CODS and LODS: Application of statutes and regulations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When an LODS or CODS contracts with an HMO to perform one or more of the functions listed in this chapter, the ODS shall comply with the standards applicable to the HMO for that function as set forth in the statutes and/or regulations applicable to HMOs, including, but not limited to, 26:2J-1 et seq., 26:2S-1 et seq., and N.J.A.C. 11:24, and all references to HMO therein shall be read to mean ODS.
(b) When an LODS or CODS contracts with carriers other than HMOs to perform one or more of the functions listed in this chapter, the ODS shall comply with the standards applicable to the non-HMO carrier for that function as set forth in the statutes and regulations applicable to that non-HMO carrier, including but not limited to, N.J.S.A. 26:2S-1 et seq., and N.J.A.C. 11:24A, and all references to carrier therein shall be read to mean ODS.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.4 - ODS: performance of health care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to qualify for certification to provide or arrange for the provision of the performance of health care services only, an ODS shall:
1. Submit a statement certifying that the ODS shall not engage in the performance of any of the other functions set forth in this chapter for which certification is required;
2. Demonstrate that its contracted health care providers are credentialed, providing a description of the credentialing standards and procedures that the ODS uses;
3. Submit a statement specifying whether all contracted health care providers are required to become participating providers with all carriers with which the ODS contracts, for all products, or whether a health care provider may limit participation; and
4. Submit a statement that the ODS shall provide written notice to the Department no later than 10 business days following the date that the ODS alters the types of health care services the performance of which the ODS provides or arranges to provide under contract with one or more carriers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.5 - ODS: network management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to qualify for certification to perform network management, an ODS shall comply with the requirements of 11:24B-3.4(b), and shall perform the following duties, meeting the standards of this section:
1. Recruiting, and maintenance of provider relations systems, in order to assure constant network adequacy with respect to the categories of providers to be included in the ODS' network;
2. Implementation and maintenance of a provider participation panel for the ODS' network;
3. Implementation and maintenance of a credentialing and recredentialing mechanism for the ODS' network;
4. Implementation and maintenance of a provider notice and termination hearing mechanism for the ODS' network;
5. Implementation and maintenance of a complaint mechanism for providers in the ODS' network;
6. Designation of a medical director licensed to practice medicine in New Jersey; and
7. Implementation and maintenance of a continuous quality improvement program for the ODS' network.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.6 - ODS: credentialing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If an ODS performs credentialing and recredentialing activities, whether with respect only to the ODS' contracted providers or other providers that may be contracted with the carrier directly or through another ODS, the ODS shall demonstrate that it meets the following requirements:
1. Credentialing and recredentialing shall be under the supervision of a medical director who is a physician licensed to practice medicine in New Jersey, whether under contract with the ODS, or the carrier with which the ODS has contracted;
2. Establishment of clearly written and detailed qualifications for credentialing participating providers for each network of providers being credentialed;
3. Establishment of clearly written and detailed time frames for performing credentialing and recredentialing activities, except that in no instance shall routine recredentialing be performed less frequently than once every 36 months;
4. Establishment of a mechanism for ensuring review of provider credentials by a multidisciplinary team;
5. Establishment of a system for verification of provider credentials, recertifications, performance reviews and obtaining information about any disciplinary action against the provider available from the New Jersey Board of Medical Examiners or any other State licensing board applicable to the type of provider, and the Federal Clearinghouse established pursuant to the Health Care Quality Improvement Act, Pub.L. 99-660 ( 42 U.S.C. §§
											1101 et seq.), and any amendments thereto; and
6. Establishment of a system assuring that the ODS' functions are linked and coordinated with the carrier's (or the carrier's contractor's) continuous quality improvement and complaint systems.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.7 - ODS: utilization management guidelines development

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for an ODS to be certified to perform development of UM guidelines, the ODS shall comply with the following:
1. The ODS shall designate a medical director to be responsible for its UM guidelines program who is licensed to practice medicine in New Jersey; or acknowledge that its utilization management program is under the ultimate oversight of the medical director of the carrier with respect to the carrier's health benefits plans, and the carrier's medical director is licensed to practice medicine in New Jersey; and
2. The UM guidelines developed by an ODS shall:
i. Be a written plan that is reviewed at least annually, and updated as appropriate, and which specifies at least the following:
(1) The procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;
(2) The mechanisms to detect underutilization and over utilization of services; and
(3) The clinical review criteria and protocols used in decision-making; and
ii. Be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be based upon generally accepted medical standards.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.8 - ODS: utilization management program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for an ODS to be certified to operate a utilization management program, the ODS shall comply with the requirements of 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f), and:
1. Have a mechanism that ensures consistent application of review criteria and uniform decisions; and
2. Develop measures for evaluating the UM guidelines and application thereof, including outcome and process measures when the carrier utilizes a gatekeeper system or practice guidelines for managed care products.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.9 - Utilization management appeal mechanism

Current through Register Vol. 56, No. 14, July 15, 2024
In order for an ODS to be certified to perform duties with respect to a carrier's utilization management appeal mechanism, the ODS shall comply with the requirements of 11:24-8.4 through 8.6 or 11:24A-3.5 and 4.12, and 26:2S-11.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.10 - ODS: continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
In order for an ODS to be certified to perform continuous quality improvement on behalf of a carrier, the ODS shall demonstrate compliance with the requirements of 11:24B-3.5(h) and (i).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.11 - ODS: provider complaint mechanism

Current through Register Vol. 56, No. 14, July 15, 2024
In order for an ODS to be certified to perform provider complaint functions on behalf of a carrier, the ODS shall demonstrate that it is in compliance with the requirements of 11:24-3.7(b)  or 11:24A-4.6(b).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 3 - FUNCTIONAL OBLIGATIONS OF AN ORGANIZED DELIVERY SYSTEM › Section 11:24B-3.12 - ODS: member complaint mechanism

Current through Register Vol. 56, No. 14, July 15, 2024
In order for an ODS to be certified to perform member complaint functions on behalf of a carrier, the ODS shall demonstrate that it is in compliance with the requirements of 11:24-3.7(a)  or 11:24A-4.6(a).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter shall apply to all contracts between a carrier and a CODS or LODS, and to all contracts between two or more ODSs, at least one of which is contracted with a carrier for the performance of one or more functions set forth in 11:24B-2.4(a).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.2 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All management agreement forms shall contain the following:
1. A provision specifying that the contract and amendments thereto are subject to prior approval of the Department, and may not be effectuated without such approval.
i. The provision may state that the following types of amendments do not require prior approval:
(1) Amendments that are of a clerical nature;
(2) Amendments which alter numbers, be they dollar amounts, enrollment amounts or the like, without altering methodologies from which the numbers were derived; and
(3) Amendments that involve the substitution of one set of variable text for another set of variable text, if both sets of variable text were previously approved for the management agreement form;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.3 - Termination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to complying with 11:24B-4.2(a)10, every contract shall specify which terms of the contract survive termination, and the duration of such survival.
(b) When an ODS is engaged in network management, the contract shall include a provision for the continuation of the services of the providers under contract with the ODS as necessary to comply with 26:2S-9.1 and 26:2J-11.1, and rules promulgated pursuant thereto, as appropriate to the types of providers and the carrier.
(c) Every contract shall include a provision that specifies continued access to books and records of the ODS by the carrier for a period of time following termination of the contract at least for the purpose of collecting data that the carrier is required to report to the Department for any part of a calendar year in which the management agreement between the ODS and the carrier was in effect.
(d) Every contract shall include a provision that specifies an orderly transfer of carrier-owned records between the ODS and the carrier, or between the ODS and another ODS on behalf of the carrier, in the event of termination of the contract between the carrier and the first ODS.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.4 - Network management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall detail the functions that the ODS is obligated to perform on behalf of the carrier with respect to network management, including all health care services and supplies the ODS will arrange to have provided to the carrier's covered persons.
(b) The contract shall specify the factors and thresholds that obligate the ODS to expand or limit the number of providers within its network in order to assure that its network meets the requirements of 11:24-6.2 and 6.3, or 11:24-4.1 0, as appropriate to the type(s) of providers in, and the health care services to be offered through, the network and as appropriate to the type of carrier under contract.
(c) The contract shall specify the compensation arrangement between the ODS and the health care providers in the network.
1. The compensation arrangement shall not provide financial incentives to the providers for the withholding of covered health care services that are medically necessary.
i. An ODS shall not be precluded from using capitated payment arrangements between the ODS and a provider.
ii. Notwithstanding (c)1i above, an ODS shall not use capitation as the sole method of reimbursement to providers who provide primarily supplies (for instance, prescription drugs or durable medical equipment) rather than services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.5 - Credentialing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall specify the party with which the medical director responsible for the credentialing program is employed or affiliated.
(b) The contract shall specify the responsibilities of the ODS and the carrier with respect to the credentialing program, including the transfer of information, and the manner in which the ODS' credentialing program coordinates with the carrier's continuous quality improvement program and complaint system(s), and what obligation the carrier has to assure compliance by providers and other ODS' to comply with the credentialing ODS' standards.
(c) The contract shall specify the time frames for performance of credentialing and recredentialing.
(d) The contract shall specify the composition of the multidisciplinary team that will review provider credentials.
(e) The contract shall specify the verification system and standards that the ODS shall use.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.6 - Utilization management guidelines development

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall detail the services that the ODS is performing on behalf of the carrier, specifying the general areas of health care services for which the UM guidelines are being developed or maintained.
(b) The contract shall specify that the ODS is obligated to assure and provide demonstration of involvement of practicing physicians and other licensed providers in the development and review of UM guidelines.
1. If the area of health care services for which UM guidelines are being developed and maintained is limited, the ODS and carrier may agree that involvement of practicing physicians and other licensed health care providers may be limited to those providers engaged in the provision of the types of health care services at issue; however, if such a limitation applies, this shall be stated in the contract with specificity as to composition of the committee(s) that the ODS will utilize to develop and review the guidelines.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.7 - Utilization management program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall specify the features of the ODS' program that assure its compliance with 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f) and 4.11(b)2, as appropriate to the carrier with which the ODS is contracted, and the health benefits plans for which UM will be provided.
(b) The contract shall specify the obligation of the ODS to develop measures evaluating UM guidelines and application thereof consistent with 11:24B-3.7(a)2, to make the information obtained from the evaluations available to the carrier, and to coordinate with the carrier's continuous quality improvement program and complaint system(s).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.8 - Utilization management appeal program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall specify how the ODS will comply with 11:24A-3.5, 11:24-8.4 through 8.6 or 11:24A-4.1 2, as applicable.
(b) If the ODS and the carrier agree that the ODS will review UM appeals submitted by a provider without requiring the consent of the covered person, the contract shall specify this, and contain provisions requiring the ODS to notify the provider and provide information in accordance with 11:24B-3.8(b).
(c) The contract shall specify the address of the entity(ies) to which covered persons and providers acting on behalf of covered persons shall be referred for purposes of pursuing a Stage 1 and Stage 2 appeal, as set forth in N.J.A.C. 11:24-8 and 11:24A-3.5, including the availability of telephonic access.
1. Notwithstanding the address specified, the contract shall specify the obligation of the ODS, when corresponding with a covered person, to always identify that the ODS is acting on behalf of the carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.9 - Continuous quality improvement program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall contain provisions that assure the ODS' ability to demonstrate compliance with 11:24B-3.3(h) and (i), except that, if the ODS is agreeing to perform continuous quality improvement only with respect to health benefits plans that are not managed care plans, the contract may contain provisions that demonstrate compliance with 11:24A-3.8.
(b) The contract shall specify the composition of committees that will address continuous quality improvement activities.
(c) The contract shall specify how the ODS' continuous quality improvement program will coordinate with complaint, appeal and credentialing programs of the carrier.
(d) The contract shall specify when and how information will be transferred between the ODS and the carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.10 - Complaint mechanisms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The contract shall contain provisions demonstrating the ODS' compliance with 11:24-3.7(b)  or 11:24A-4.6(b)  if addressing provider complaints, or 11:24-3.7(a)  or 11:24A-4.6(a)  if addressing complaints of covered persons.
(b) The contract shall specify the authority of the ODS to resolve complaints, and the carrier to be bound by the ODS' resolution of complaints when in favor of the covered person or provider.
(c) The contract shall specify the mechanism the ODS has in place to track and maintain records of complaints, including follow-up and the resolution of complaints, the duration for which records of complaints will be maintained, the data that the ODS will collect for the carrier, and the process for transferring information regarding complaints between the carrier and the ODS.
1. Complaint records shall be maintained for no less than four years.
2. The data to be collected shall be at least that information required for the carrier to submit reports to DOBI.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.11 - Issuance of contracts on approved forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No ODS or carrier shall execute a contract or an amendment to a contract for a management agreement unless the form thereof has been approved by the Department.
(b) The following are amendments that may be effectuated without approval of the Department:
1. Amendments that are of a clerical nature;
2. Alterations to numbers, whether dollar amounts, enrollment amounts or the like, so long as there is no alteration of the methodologies from which the numbers were derived; and
3. The application of one variable provision in lieu of another variable provision, so long as both variable provisions were approved by the Department within the same form of management agreement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS › Section 11:24B-4.12 - Review and approval of management agreements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Management agreements submitted with the initial application for certification or an application for licensing shall be subject to the standards for submission, review and approval as set forth at N.J.A.C. 11:24B-2.
(b) Amendments to forms of management agreements shall be submitted to the Department for review and approval no less than 60 days prior to the date that the ODS intends to use any amendment.
(c) The Department shall approve or disapprove the management agreement form within 60 days of the date of receipt of the form, unless the Department extends its review period for an additional 30 days by notifying the ODS in writing of the extension.
1. In the event that the Department does not affirmatively approve or disapprove the form, or notify the ODS of the extension of the review period, prior to the end of the 60-day period, the form may be deemed approved.
2. Notwithstanding (c)1 above, neither an ODS nor a carrier shall effectuate any amendment to a management agreement deemed approved unless the ODS has submitted a statement in writing to the Department that it is deeming the amended form approved in accordance with (c)1 above, stating the date of deemed approval, and that the ODS is using it accordingly.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter shall apply to all provider agreements for the delivery of one or more health care services to a covered person of a carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.3 - Termination and continuity of care standards for contracts with health care professionals

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.