New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24B - ORGANIZED DELIVERY SYSTEMS › Subchapter 5 - PROVIDER AGREEMENTS › Section 11:24B-5.2 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All provider agreement forms shall comply with the requirements set forth at N.J.A.C. 11:24C-4 and shall contain:
1. A provision specifying that any sections of the contract that conflict with State or Federal law are effectively amended to conform with the requirements of the State or Federal law;
2. A provision specifying the compensation methodology.
i. The provision shall not provide financial incentives to the provider for the withholding of covered health care services that are medically necessary, but this shall not prohibit or limit the use of capitated payment arrangements between an ODS and a provider.
ii. To the extent that some portion of the provider compensation is tied to the occurrence of a pre-determined event, or the non-occurrence of a pre-determined event, the event shall be clearly specified, and the ODS shall include in its contracts a right of each provider to receive a periodic accounting of the funds held, which shall be no less frequently than annually.
iii. The provision shall specify that a provider may appeal a decision denying the provider additional compensation to which the provider believes he or she is entitled under the terms of the provider agreement.
iv. Notwithstanding (a)2i above, capitation shall not be the sole method of reimbursement to providers that primarily provide supplies (for instance, prescription drugs or durable medical equipment) rather than services.
v. In no event shall the provision indicate that the compensation terms will be determined subsequent to the execution of the contract between the ODS and the provider.
3. A provision specifying that the provider's activities and records relevant to the provision of health care services may be monitored from time to time either by the ODS, the carrier, or another contractor acting on behalf of the carrier in order for the ODS or the carrier to perform quality assurance and continuous quality improvement functions;
4. A provision explaining the quality assurance program with which the provider must comply.
i. The provision shall specify whether the quality assurance program is that of the ODS and is being adopted by the carrier, is that of the carrier and is being adopted by the ODS, or is that of a separate entity and is being adopted by both the carrier and the ODS with which the provider is contracted.
ii. The provision shall specify the entity that is responsible for the day-to-day administration of the quality assurance program.
iii. The provision shall specify the entity with which the provider may lodge complaints regarding the quality assurance program, and otherwise provide information on how provider feedback regarding the operations of the ODS and carrier operations will be elicited;
5. A provision explaining the utilization management program with which the provider must comply.
i. The provision shall specify whether the utilization management program is that of the ODS and is being adopted by the carrier, is that of the carrier and is being adopted by the ODS, or is that of a separate entity and is being adopted by both the carrier and the ODS with which the provider is contracted.
ii. The provision shall explain what entity is responsible for the day-to-day operation of the utilization management program, how the provider is to comply with the UM standards, including the method for obtaining a UM decision and appealing UM decisions, and the right of the provider to have the name and telephone number of the physician, or dentist if appropriate to the services at issue, denying or limiting an admission, service, procedure or length of stay.
iii. The provision shall explain how providers may receive information regarding the UM protocols and any parameters that may be placed on the use of one or more protocols.
iv. The provision shall explain how participating providers may review and provide comment on the applicable protocols for the provider's practice area.
v. The provision shall explain that the provider has the right to rely upon the written or oral authorization of a service if made by the carrier or the entity identified as being responsible for the day-to-day operations of the utilization management program, and that the services will not be retroactively denied as not medically necessary except in cases where there was material misrepresentation of the facts to the carrier or the entity identified as being responsible for the day-to-day operations of the utilization management program, or fraud;
6. A provision explaining the rights and obligations of the provider when appealing a UM decision on behalf of a covered person, including the right to receive a written notice of the UM determination.
i. The provision shall be clear as to whether the provider must obtain consent of the covered person in order for the appeal to be reviewed in accordance with the Stage 1 and Stage 2 process as set forth at N.J.A.C. 11:24-8 and 11:24A-3.5, or whether failure to obtain consent of the covered person results in review of the appeal using a separate complaint or provider grievance process.
ii. In the event that an appeal instituted by a provider on behalf of a covered person will be entertained as a member utilization management appeal without the covered person's consent, the provision shall explain that such appeals will not be eligible for the Independent Health Care Appeals Program, established pursuant to 26:2S-11, until the covered person's specific consent to the appeal is obtained.
iii. The provision shall not limit the right of the provider to submit an appeal on behalf of the covered person to situations in which the covered person may be financially liable for the costs of the health care services;
7. A provision specifying that the contract is governed by New Jersey law;
8. A provision specifying the term of the contract.
i. Every provider agreement shall specify the date the contract is executed, which shall not be prior to the date that the ODS is first certified to operate in New Jersey, except as 11:24B-1.3 applies.
ii. The anniversary date of the contract shall be the execution date of the contract, if no anniversary date is otherwise specified;
9. A provision specifying termination and renewal rights and obligations of the parties with respect to termination and renewal;
10. A provision prohibiting providers from billing or otherwise pursuing payment from a carrier's covered person for the costs of services or supplies rendered in-network that are covered, or for which benefits are payable, under the covered person's health benefits plan, except for copayment, coinsurance or deductible amounts set forth in the health benefits plan, regardless of whether the provider agrees with the amount paid or to be paid, for the services or supplies rendered;
11. A provision establishing the obligation of the provider to be credentialed and otherwise eligible to participate in various programs (for example, Medicare or Medicaid), as appropriate.
i. The provision shall set forth the time periods for credentialing and recredentialing of providers, and the obligation of the provider to cooperate with the credentialing process;
12. A provision setting forth the provider's obligation to maintain malpractice insurance in the amount of not less than $ 1,000,000 per occurrence and $ 3,000,000 in the aggregate per year.
i. The provision may require that the amount of malpractice insurance must be sufficient for anticipated risk, so long as the minimum amounts of $ 1,000,000/$ 3,000,000 are specified;
13. A provision setting forth the health care services and supplies that the provider is to render to covered persons;
14. A provision specifying that providers shall have the right and obligation to communicate openly with all covered persons regarding diagnostic tests and treatment options;
15. A provision specifying that providers shall not be terminated or otherwise penalized because of complaints or appeals that the provider files on his or her own behalf, or on behalf of a covered person, or for otherwise acting as an advocate for covered persons in seeking appropriate, medically necessary health care services covered under the covered person's health benefits plan;
16. A provision stating that the provider shall not discriminate in his or her treatment of a carrier's covered persons.
i. The provision may permit providers to limit the total number of a carrier's covered persons that the provider treats, so long as the standards for the limitations do not result in unfair discrimination and are set forth clearly in the provider agreement.
ii. The provision may permit the provider to limit the carrier's products for which the provider will be considered a participating provider, so long as the standards for the limitations are set forth clearly in the provider agreement;
17. A provision setting forth the procedures for submitting and handling of claims, including any penalties that may result in the event that claims are not submitted timely, the standards for determining whether submission of a claim has been timely, and the process for providers to dispute the handling or payment of claims.
i. Provisions addressing claims handling shall be consistent with applicable law.
ii. The provision shall specify how interest for late payment of claims shall be remitted to the provider, but in no instance shall the provision obligate the provider to request payment of the interest before the interest will be paid;
18. A provision explaining how the provider may submit and seek resolution of complaints and grievances, separate and apart from submitting complaints and grievances on behalf of a covered person, and complaints addressing compensation and claims issues.
i. The provision shall specify the time frames for resolving complaints and grievances, which shall not exceed 30 days following receipt of the complaint or grievance.
ii. The provision shall explain the right of the provider to submit complaints and grievances to DOBI or DHS, depending upon the issue involved, if not satisfied with the resolution of the complaint or grievance through the internal provider complaint mechanism; and
19. A provision setting forth the confidentiality requirements that may apply to various records, including medical records, that the parties may maintain pursuant to their contractual relationship.