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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Appendix - APPENDIX › Exhibit GG

Current through Register Vol. 56, No. 14, July 15, 2024
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A separate Report Form shall be completed and filed for each affiliate in addition to a combined report form for affiliated insurance companies or affiliated HMOs. Definitions and instructions regarding words and terms appearing below may be found on the reverse side.
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I certify that the above information is accurate and complete and has been prepared in accordance with N.J.A.C. 11:21-7A. If dividends (or credits) are required, an explanation of our plan to issue them is attached.
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REPORTING FORM DEFINITIONS AND INSTRUCTIONS
1. "Premiums" are the total earned premiums, on the same earned basis as in the carrier's Annual Statement for the preceding calendar year, before dividends or credits applicable to prior years: (a) combined for all Standard Health Benefits Plans; (b) combined for open Nonstandard Health Benefits Plans; and (c) combined for Closed Nonstandard Health Benefits Plans. Include all Rider Premiums, both Standard and Nonstandard Riders, with the respective Plans which are ridered. The Closed Nonstandard Plans column is for the policies which are renewal only policies continued pursuant to N.J.S.A. 17B:27A-19j(3)(b).
2. "Claims" are equal to:
a. claims paid in the preceding calendar year regardless of the year incurred;
b. plus claims paid from January 1 through June 30 of the reporting year for claims incurred prior to January 1 of the reporting year;
c. less claims paid from January 1 through June 30 of the preceding calendar year for claims incurred prior to January 1 of the preceding calendar year (as reported in the preceding year's Loss Ratio Report);
d. plus a residual reserve equal to 3.3 percent of a. + b.-c.;
e. less the residual reserve as reported in the preceding calendar year's Loss Ratio Report.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Appendix - APPENDIX › Exhibit HH

Current through Register Vol. 56, No. 14, July 15, 2024
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The amended version of this Section by 53 N.J.R. 1738(a), effective 8/27/2021 is not yet available.
The repealed version of this exhibit 55 N.J.R. 196(a), effective 1/1/2023 is not yet available
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM › Appendix - APPENDIX › Exhibit II

Current through Register Vol. 56, No. 14, July 15, 2024
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The amended version of this Section by 53 N.J.R. 1738(a), effective 8/27/2021 is not yet available.
The repealed version of this exhibit 55 N.J.R. 196(a), effective 1/1/2023 is not yet available
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter implements 17B:30-26 through 34, which sets standards for the payment of claims relating to health benefit plans and dental plans.
(b) This chapter applies to any insurance company, health service corporation, medical service corporation, hospital service corporation, health maintenance organization, prepaid prescription service organization, dental service corporation, and dental plan organization that issues health benefits plans, prescription drug plans, and/or dental plans in this State; any organized delivery system; and to any agent, employee or other representative of such entity that processes claims for such entity.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.3 - Acknowledgement of receipt of claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier or its agent shall acknowledge receipt of all claims. The acknowledgement shall include the date the carrier or its agent received the claim.
1. If a claim is submitted by electronic means, the claim shall be acknowledged electronically no later than two working days following receipt of the claim. The acknowledgement of receipt of an electronic claim shall go to the entity from which the carrier received the claim.
2. If a claim is submitted by written notice, the claim shall be acknowledged no later than 15 working days following receipt of the claim.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.4 - Claim submission requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A health carrier or its agent shall provide in a clear and conspicuous manner through a publicly accessible internet website information concerning the submission and processing of claims including, but not limited to, where applicable:
1. A list of the material, documents, or other information required to be submitted to the health carrier or its agent with a claim for payment for health care services or supplies;
2. A description of claims for which the submission of additional documentation or information is required for the adjudication of a claim fitting that description, and an explanation of the additional information required;
3. The policy or procedure for reducing the payment for multiple services or supplies provided by a health care provider on the same date;
4. The policy for payment to assistant surgeons;
5. The policy for reimbursement for administration of immunization and injectable medications;
6. The policy regarding recognition of procedure modifiers;
7. Identification of the source of all commercially produced clinical criteria guidelines and a copy of all internally produced clinical criteria guidelines used by the health carrier or its agent to determine the medical necessity of health care services;
8. A street address where claim submissions can be delivered by hand or registered/certified mail if the claim is submitted by other than electronic means; and
9. The health carrier's application for a provider's internal appeal of a payment dispute.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.5 - Prompt payment of claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier and its agent shall remit payment of clean claims pursuant to the following time frames:
1. Thirty calendar days after receipt of the claim where the claim is submitted by electronic means or the time established for the Federal Medicare program by 42 U.S.C. §
											1395u(c)2(B), whichever is earlier; or
2. Forty calendar days after receipt of the claim where the claim is submitted by other than electronic means.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.6 - Denied and disputed claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier or its agent shall either deny or dispute a claim, in full or in part, that has not been processed according to
11:22-1.5
. If only a portion of a claim is disputed or denied, the carrier or its agent shall remit payment for the uncontested portion in accordance with
11:22-1.5
. A carrier's or its agent's characterization of a claim as pending shall not release the carrier of its obligation to either deny or dispute a claim in accordance with this section. The carrier or its agent shall, within 30 or 40 calendar days of receipt of the claim, whichever is applicable, notify the covered person, when he or she will have increased responsibility for payment, and the provider of the basis for its decision to deny or dispute, including:
1. The identification and explanation of all reasons why the claim was denied or disputed;
i. A carrier or its agent shall not deny or dispute a claim for reasons other than those identified in the first review after the claim is entered, unless information or documentation relevant to the claim is received after the first review and such documentation leads to additional reasons to deny or dispute which were not present at the time of that review.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.7 - Prompt payment of capitation payments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Payment of a capitation payment to a health care provider shall be deemed to be overdue if not remitted to the provider on the fifth business day following the due date of the payment in the contract, if:
1. The health care provider is not in violation of the terms of the contract; and
2. The health care provider has supplied such information to the insurer as may be required under the contract before payment is to be made.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.8 - Reimbursement of overpaid claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No carrier or its agent shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances:
1. In judicial or quasi-judicial proceedings, including arbitration;
2. In governmental administrative proceedings;
3. Where relevant records required to be maintained by the provider have been improperly altered or reconstructed, or a material number of such records are unavailable; or
4. Where there is clear evidence of fraud by the health care provider and, if applicable, the carrier has investigated the claim in accordance with its fraud prevention plan established pursuant to
17:33A-15
and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety and the Bureau of Fraud Deterrence in the Department pursuant to
17:33A-9
.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.9 - Reimbursement of underpaid claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No health care provider shall request reimbursement from a health carrier or its agent or from a covered person later than 18 months from the date the first payment on the claim was made unless the claim is the subject of an internal appeal pursuant to
11:22-1.10
or is subject to continual claims submission.
1. The written reimbursement request shall be a separate notice to the health carrier or its agent or the covered person and shall include:
i. A clear identification of the claim;
ii. The name of the health care provider's patient and the date of service; and
iii. An explanation of the basis upon which the health care provider believes the amount paid on the claim was less than the amount due.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.10 - Internal appeals-health carriers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every health carrier or its agent shall establish an internal appeals mechanism to resolve payment disputes between health carriers or their agents and health care providers, but not including appeals related to medical necessity made pursuant to
11:24-8.5
,
8.6
, and
8.7
and
11:24A-3.5
,
3.6
, and
3.7
. The internal appeals mechanism shall be described in the participating provider contract and in a publicly available internet website.
1. A health care provider may initiate an appeal of a health carrier's or its agent's claim determination:
i. Within 90 calendar days of receipt of the health carrier's or agent's determination that is the basis of the appeal; or
ii. Within 90 calendar days of a health carrier's or its agent's missed due date for the claim determination, including at the provider's option, a claim that has been pended.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.11 - Internal appeals-dental plan organizations and dental service corporations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every dental plan organization and dental service corporation shall establish an internal appeals mechanism to resolve disputes between dental carriers or their agents and participating health care providers relating to payment of claims for services or supplies covered by a dental plan. The internal appeal mechanism shall be described in the participating provider contract.
1. The internal review shall be conducted by employees of the dental carrier who shall be personnel other than those responsible for claims payment on a day-to-day basis and shall be provided at no cost to the provider.
2. The internal review shall be conducted and its results communicated in a written decision to the provider within 30 days of receipt of the appeal. The written decision shall include:
i. The names, titles, and qualifying credentials of the persons participating in the internal review;
ii. A statement of the participating provider's grievance;
iii. The decision of the reviewers, along with a detailed explanation of the contractual and/or medical basis for such decision;
iv. A description of the evidence or documentation which supports the decision; and
v. If the decision is adverse, a description of the method to obtain an external review of the decision.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.12 - External appeals-alternative payment dispute resolution-dental plan organizations and dental service corporations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every dental plan organization and dental service corporation shall offer an independent, external alternative payment dispute resolution (ADR) mechanism to participating health care providers to review adverse decisions of its internal appeals process.
1. The ADR mechanism shall be through an independent party. The costs of the process shall be borne equally by the parties. The recommended decision of the ADR mechanism shall be issued no later than 30 business days from receipt by the ADR firm of all documentation necessary to complete the review.
2 The ADR mechanism, including the method to submit a claim through such mechanism, shall be described in the participating provider contract and in the final internal decision denying or disputing the participating health care provider's claim, in full or in part.
3. The decision of the ADR mechanism shall be non-binding unless the parties agree otherwise.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.13 - External appeals-health carriers-arbitration

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any dispute regarding the determination of an internal appeal conducted pursuant to a health carrier's or its agent's internal appeal mechanism established pursuant to P.L. 2005, c. 352, and described at
11:22-1.10
, may be referred to arbitration, except for the following disputes that are eligible to be submitted to the Independent Health Care Appeals Program established pursuant to
26:2S-11
. The disputes shall involve whether:
1. A treatment or service is medically necessary;
2. A treatment or service is experimental or investigational;
3. A treatment or service is cosmetic;
4. A treatment or service is medical or dental;
5. A condition is a preexisting condition; and
6. The health carrier should authorize services to be performed by an out-of-network provider but hold the member responsible for in-network cost sharing only because the carrier's network lacks a provider who is accessible and possesses the requisite skill and expertise to perform the needed services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.14 - Reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A carrier or ODS shall report to the Department on a quarterly and annual basis on the timeliness of claims payments and on the reasons for denial and late payment of claims in a format set forth by bulletin or similar means and/or on the Department's website. Due dates for the reports are as follows: May 15 for the first quarter; August 15 for the second quarter; November 15 for the third quarter; and March 31 for the annual report.
(b) The annual report on the timeliness of claims payments and on the reasons for denial and late payment of claims shall be audited by a private auditing firm at the expense of the carrier or ODS. The annual report shall be accompanied by the report of the auditing firm that reviewed the report. In addition to the Department, copies of the audited annual report shall be sent to the Governor and the majority and minority offices of the Legislature.
(c) The report shall be submitted by the due date to:
New Jersey Department of Banking and Insurance
Life & Health Actuarial, 11th Floor
Prompt Payment Reports
20 West State Street (for private Express Delivery)
PO Box 325 (for regular US mail)
Trenton, New Jersey 08625-0325
(d) All quarterly reports shall be submitted by the due date as an Excel spreadsheet through the State Electronic Rate and Form Filing System.
(e) A carrier or ODS may request an exemption from the requirements to have the annual report audited and to submit a report of the auditing firm. This exemption must be obtained on an annual basis. Such an exemption may be granted if the carrier or ODS meets the following conditions:
1. The carrier or ODS must file the annual report in a timely manner. The report shall be accompanied by a request for exemption from the requirements that the report be audited and that a report of the auditing firm be submitted; and
2. The annual premiums earned by the carrier or ODS in New Jersey for all health benefits plans as defined in
11:22-1.2
were less than $ 5 million in the year covered by the annual report for which the exemption is requested. The carrier or ODS shall provide, in its request for exemption, a copy of the report of net earned premiums submitted to the Commissioner pursuant to
11:4-23A.8(a)
1 or, alternatively, other evidence acceptable to the Commissioner that premiums are less than $ 5 million.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.15 - Remediation/penalty

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon review of the reports required by
11:22-1.14
, the Commissioner may require that the carrier , ODS, or the agent of a carrier or ODS, at its own expense:
1. Implement a plan of remedial action; and/or
2. Have the claims processing procedures of the carrier or its agent be monitored by a private auditing firm for a period to be determined by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.16 - Explanation of benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan.
(b) The explanation of benefits shall include at least the following information:
1. Name of the covered person;
2. Name of the provider;
3. Date of service;
4. Clear description of the service;
5. Billed charge;
6. Allowed charge;
7. Non-covered amount;
8. A specific explanation of why a charge is not covered by the health benefits plan, for example, person not covered on date of service, provider not in network, other coverage is primary, the service is not medically necessary, no prior authorization, no referral, experimental or investigational service, or service is excluded by contract. Use of denial reasons with multiple grounds shall only be used if each denial ground applies to the specific claim, including when the reasons are separated by an "and," similar text, symbol, or punctuation;
9. The amount that is the covered person's responsibility due to deductible, coinsurance, and copayment;
10. The accumulation toward the covered person's deductible, or family deductible, if applicable;
11. The accumulation toward the covered person's maximum out-of-pocket, or family maximum out-of-pocket, if applicable;
12. Amount paid by plan, interest should be shown separately if interest is paid;
13. An explanation of the process to appeal the determination on the claim; and
14. A telephone number that the covered person can call to get additional information on the processing of the claim.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 2 - HEALTH WELLNESS PROMOTION PLANS › Section 11:22-2.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter applies to health benefits plans that are delivered, issued, executed or renewed in this State on or after (the effective date of this subchapter).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 2 - HEALTH WELLNESS PROMOTION PLANS › Section 11:22-2.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the meanings as set forth below, unless the context clearly indicates otherwise:
"Act" means the Health Wellness Promotion Act, P.L. 1993, c.327, as amended by P.L. 1999, c. 339.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.
"Department" means the Department of Banking and Insurance.
"Health benefits plan" means an individual or group contract issued by a carrier that provides hospital and medical expense benefits or services. Health benefits plan does not include the following types of policies or contracts: health benefit plans subject to 17B:27A-2 et seq. (Individual Health Coverage Program) or 17B:27A-17 et seq. (Small Employer Health Program); accident only, credit, disability, hospital confinement indemnity, long-term care, vision only, dental only, prescription only, CHAMPUS supplement, Medicare supplement, coverage for Medicare services pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance or other liability-based medical payment insurance, or personal injury protection insurance issued pursuant to 39:6A-1 et seq.
"Health care provider" or "provider" means an individual or entity which, acting within the scope of its license or certification, provides a covered service or supply as defined by the health benefits plan. Health care provider includes, but is not limited to, the health professions specified in N.J.S.A. 17B:48E-12, 17B:27-50 and 17B:27-51.1a.
"Health wellness promotion program" means services or benefits for services rendered by a health care provider, which services or benefits are consistent with this subchapter, and any bulletins and public notices that may be issued in accordance with this subchapter as a supplement to this subchapter.
"Schedule" means the number of times a test, screen or other service must be covered or benefits provided therefor in a specified period.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 2 - HEALTH WELLNESS PROMOTION PLANS › Section 11:22-2.3 - Provision of a health wellness promotion program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every health benefits plan issued by a carrier shall provide benefits for a health wellness promotion program, which shall include, at a minimum, the following tests and services:
1. For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level;
2. For all persons 35 years of age or older, a glaucoma eye test every five years;
3. For all persons 40 years of age or older, an annual stool examination for presence of blood;
4. For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years;
5. For all women 20 years of age or older, a pap smear as required by N.J.S.A. 17:48-60, 17:48E-35.1 2, 17B:27-46.1n, or 26:2J-2.1 2, as applicable;
6. For all women 40 years of age or older, a mammogram examination as required by 17:48-6g, 17:48-7f, 17:48E-35.4, 17B:26-2.1e, 17B:27-46.1f, or 26:2J-4.4, as applicable;
7. For all adults, recommended immunizations according to the latest edition of the Guide for Adult Immunization, third ed., published by the American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572 (
http://www.acponline.org
) incorporated herein by reference, as amended and supplemented; and
8. For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 2 - HEALTH WELLNESS PROMOTION PLANS › Section 11:22-2.4 - Dollar amounts to be provided for services or benefits

Current through Register Vol. 56, No. 14, July 15, 2024
The Department and the Department of Health and Senior Services for HMO's, in consultation with the Department of Treasury, shall calculate the maximum dollar amount of services or benefits to be provided no later than July 1 annually, and shall publish the results of the calculation as a public notice in the New Jersey Register and post it on the web site of each Department.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 17B:30-23 et seq., P.L. 1999, c. 154 (the Health Information Electronic Data Interchange Technology Act ("HINT" or "the Act")), the purpose of this subchapter is to establish timetables for the introduction and implementation of systems for the electronic receipt and transmission of health care claim information, including, but not limited to, eligibility, premium payments, reports of injury, claim status, referral requests, authorization for referral, enrollment, disenrollment, and other health care claims transactions in accordance with the standards developed by the United States Department of Health and Human Services (hereinafter referred to as "DHHS") pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191 ("HIPAA") for the electronic administration of health care benefits.
(b) In accordance with N.J.S.A. 17B:30-23b, this subchapter also establishes one set of standard health care enrollment and claim forms in paper and electronic formats to be used by all health care benefit payers referred to in (d) below.
(c) Pursuant to 45:1-10.1 and 26:2H-12.1 2, this subchapter also establishes rules requiring health care professionals, institutions and facilities to file claims on behalf of their patients when seeking payment or reimbursement of health care claims.
(d) The subchapter applies to all hospital service corporations; medical service corporations; health services corporations; health insurers issuing individual policies of insurance; health insurers issuing group policies of insurance; health maintenance organizations; dental service corporations; dental plan organizations; and prepaid prescription service organizations; as well as any subsidiary or agent of any such entity, company or organization that may process health benefit information on behalf of a payer.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.3 - Standard enrollment/change request forms and application/change request forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
									45 C.F.R. 162.1101, Subpart K, the Health Care Claims or Equivalent Encounter Information Standard, and 45 CFR 162.1501, Subpart O, the Enrollment and Disenrollment in a Health Plan Standard, are adopted by the Department, in consultation with the Department of Health and Senior Services, as the electronic standard format for enrollment, disenrollment and claim forms, and are incorporated and made a part herein by reference.
(b) The UB-04, CMS 1450 (the uniform claim form for use by health care institutions and facilities) and the CMS-1500 (the uniform claim form for use by health care providers) are recognized and adopted by the Department, in consultation with the New Jersey Department of Health and Senior Services, as the paper standard format for claims by medical institutions, facilities and providers. Information concerning these forms is located at the website maintained by the Centers for Medicare and Medicaid Services (CMS),
http://www.cms.gov
and incorporated herein by reference.
(c) The paper standard formats for a universal enrollment/change request form and application/change request form for health insurance coverage can be accessed via the Department's website at
http://www.state.nj.us/dobi/formlist.htm#insuranceformsandapps
.
1. The enrollment/change request form requests or contains the following information:
i. The type of activity (for example, new enrollee/subscriber, a change in covered person(s), removal or termination of a covered person(s) or request for continuation of coverage);
ii. Employee information;
iii. Plan option;
iv. Individuals covered;
v. Pre-existing conditions statement;
vi. Other/previous insurance;
vii. Dependent information;
viii. Race/ethnicity (optional);
ix. Employee signature;
x. Employer verification;
xi. Instructions for completion of the form;
xii. A conditions of enrollment statement; and
xiii. A misrepresentation statement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.4 - Health care providers; claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) On or after October 1, 2002, all payers shall require that all providers file all claims for payment unless the patient, at his or her option, files the claim directly.
(b) Where a claim is being filed by the health care provider on behalf of the patient without an assignment of benefits, the provider shall file the claim within 60 days of the last date of service of that course of treatment.
(c) Where the provider is filing a claim under an assignment of benefits from the patient, the provider shall file the claim within 180 days of the last date of service of the course of treatment.
(d) In the event a health care provider does not file the claim within 180 days of the last date of service of a course of treatment referred to in (c) above, the third party payer and/or health benefit payer shall in accordance with 11:22-1.6 reserve the right to deny or dispute the claim and the health care provider shall be prohibited from seeking payment in whole or in part directly from the patient.
(e) When a health benefit payer takes action in accordance with (d) above, the health benefit payer shall advise the health care provider that payment of the claim, in whole or in part, will be made based upon consideration of the following factors that shall be addressed by the provider:
1. The good faith use of information provided by the patient to the health care provider with respect to the identity of the patient's health benefits payer;
2. Delays encountered in filing a claim related to the coordination of benefits among third party payers;
3. Whether the health care provider has previously filed untimely claims or has an established pattern of untimely claim practices;
4. Any prejudice to the rights of the patient and/or the health benefits provider in determination of the medical necessity of the services and care being billed for; and
5. Potential adverse impact to the public.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.5 - Additional timetables

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with 11:22-1.3, payers receiving an electronically filed claim shall individually acknowledge receipt of each claim by responding with a 277 Transactions, ANSI ASC X12.317, Version 003070, Release 7, Sub-release O, October 1996, Electronic Health Care Claim Status Notification acknowledgement. Nothing in this section shall prevent payers from also using any other responses including, but not limited to, the 997 Functional Acknowledgement of batch transfers in addition to providing a 277 acknowledgement.
(b) In the event a provider's system is unable to receive a 277 acknowledgement, the payer shall establish a mutually agreeable alternative means of acknowledgement with the provider.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.6 - Use of clearinghouses in electronic transactions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When computing the number of days for purposes of acknowledging an electronic claim and/or any other health care transactions required by this subchapter, the following shall apply:
1. When the provider chooses to use a clearinghouse for the transmission of claims to a payer, notice delivered by the payer to the clearinghouse shall constitute notice to the provider.
2. When a payer uses a clearinghouse for the receipt of any electronic transactions required by this subchapter, notice sent by the payer through the clearinghouse shall not constitute notice to a provider until it is delivered to the provider by the clearinghouse, or is available for pickup from the provider's mailbox at the clearinghouse.
3. When a payer and provider use the same clearinghouse for the transmission and receipt of health care transactions, notice that is sent by one party to the clearinghouse shall also constitute notice to the other party.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.7 - Information protection practices

Current through Register Vol. 56, No. 14, July 15, 2024
All information and materials coming into the possession of health benefits payers, health care providers and their agents and vendors for the administration of the health care transactions described in this subchapter are subject to and shall comply with practices and requirements established in 17:23A-1 et seq., the Insurance Information Practices Act.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.8 - Fraud prevention and detection

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All payers shall deploy as part of any system for the electronic receipt and transmission of claims an anti-fraud program, resident system and/or software that is approved by the Department's Division of Anti-Fraud Compliance.
(b) The anti-fraud system described in (a) above shall be capable, at a minimum, of the following activities:
1. Screening all claims, pre-payment and/or post-payment, for data patterns associated with fraudulent activity;
2. Responding to audit specific inquiries to facilitate fraud investigations;
3. Identifying phantom vendors, employees, patients and providers;
4. Identifying inappropriate or inconsistent charges; and
5. Scanning provider claims for unnecessary and repetitive charges.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.9 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including suspension or revocation of the payer's authority to do business in the State of New Jersey.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter sets forth the filing and requirements for an entity to be licensed as an organized delivery system pursuant to 17:48H-1 et seq.
(b) This subchapter applies to any entity seeking to become licensed as an organized delivery system pursuant to 17:48H-1 et seq.; or an existing organized delivery system required to obtain a license to operate pursuant to 17:48H-11. A non-exhaustive list of examples of entities and arrangements that are subject to these rules is set forth in Exhibit A in the Appendix to this subchapter, incorporated herein by reference.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.3 - License requirement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An organized delivery system that receives compensation on a basis that entails the assumption of financial risk shall submit an application for licensure to the Commissioner.
1. This subchapter shall apply to any contract issued and/or renewed on or after October 21, 2002.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.4 - Application procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An application for a license to operate an organized delivery system shall be filed with the Commissioner, and shall contain a completed application, containing the information and in the format set forth in Exhibit A in the Appendix to this subchapter, incorporated herein by reference. In addition, the application shall be accompanied by:
1. A non-refundable application fee in the amount of $ 2,500, payable to the Treasurer, State of New Jersey; and
2. Any additional information as may be required from a particular applicant by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.5 - Application review procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall review an application for licensure and notify the applicant of any deficiencies contained therein within 60 days of receipt. An applicant shall address any deficiencies in its application within 60 days of notice thereof.
(b) Upon receipt and review of a complete application that contains all of the information set forth in 11:22-4.4, the Commissioner shall issue a license to an organized delivery system if he or she finds that the system meets the following standards:
1. The persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have had appropriate experience, training and education;
2. The persons who are to perform the health care services are properly qualified;
3. The organized delivery system has demonstrated the ability to assure that health care services will be provided in a manner which will assure the availability and accessibility of the services;
4. The standard forms of provider agreements to be used by the organized delivery system are acceptable, and comply with all requirements set forth at N.J.A.C. 11:24C-4 and 11:24B-2;
5. The applicant is financially sound and may reasonably be expected to meet its obligations to enrollees, contract holders and carriers. In making this determination, the Commissioner shall consider:
i. The financial soundness of the applicant's compensation arrangements for the provision of health care services;
ii. The adequacy of working capital, other sources of funding (including an acceptable capital and surplus guarantee from a parent or affiliate) and provisions for contingencies;
iii. Whether any deposit of cash or securities, or any other evidence of financial protection submitted, meets the requirements set forth in 17:48H-1 et seq. and this subchapter; and
iv. The standards set forth in N.J.A.C. 11:2-27;
6. Any deficiencies identified by the Commissioner have been corrected;
7. The applicant certifies that it is familiar and will comply with all requirements of law pertaining to licensed organized delivery systems set forth in 17:48H-1 et seq. and this subchapter; and
8. Any other factors determined by the Commissioner to be relevant regarding a particular applicant have been addressed to the satisfaction of the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.6 - Notice of change in documents

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A licensed organized delivery system shall not materially modify any matter or document furnished pursuant to 11:22-4.4 unless the system files with the Commissioner a notice of the change or modification, together with any additional information to explain the change or modification, at least 60 days prior to the use or adoption of the change, and a filing fee in the amount of $ 250.00. If the Commissioner fails to affirmatively approve or disapprove the change or modification within 60 days of submission of the notice and any supporting information required by the Commissioner, the notice of modification shall be deemed approved. The Commissioner may extend the 60-day review period for not more than 30 additional days by giving written notice of the extension before the expiration of the 60-day period. If a change or modification is disapproved, the Commissioner shall notify the system in writing and specify the reason for the disapproval.
(b) Prior to entering into any contract with a carrier, a licensed organized delivery system shall file a copy of the contract with the Commissioner for approval. The filing shall be made no later than 60 days prior to the date that the contract is intended to be in effect. The Commissioner shall either approve the contract or state in writing the reasons for disapproval within 60 days of receipt of the filing. Contracts shall be subject to the following standards:
1. The terms shall be fair and reasonable;
2. Charges or fees for service performed shall be reasonable;
3. Expenses incurred and payment received shall be allocated to the system in conformity with customary accounting practices consistently applied;
4. The books, accounts and records of each party to all such transactions shall be so maintained as to clearly and accurately disclose the precise nature and details of the transactions, including such accounting information as is necessary to support the reasonableness of the charges or fees to the respective parties; and
5. The system's net worth following any transaction shall be reasonable in relation to its outstanding liabilities and adequate to its financial needs.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.7 - Examinations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner may conduct an examination of a licensed organized delivery system as often as he or she deems necessary in order to protect the interests of providers, contract holders, enrollees, and the residents of this State, but not less frequently than once every five years, except that an examination shall be conducted three years after the organized delivery system is initially licensed in this State. A licensed organized delivery system shall make its relevant books and records available for examination by the Commissioner, and retain its records related to the next examination, for not less than seven years. The reasonable expenses of the examination shall be borne by the licensed organized delivery system being examined.
(b) Where the system is domiciled in another state, and subject to regulation in a manner substantially similar to that provided under 17:48H-1 et seq. and this subchapter, the Commissioner may accept the report of an examination made by the Commissioner of that state in lieu of conducting examination pursuant to this section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 4 - ORGANIZED DELIVERY SYSTEMS › Section 11:22-4.8 - Net worth, deposits, and bond

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Except as provided in (i) below, a licensed organized delivery system shall, at all times, have and maintain a minimum net worth, determined on a statutory accounting basis, in an amount equal to the greater of:
1. Two percent of the annual compensation received by the organized delivery system for all of its contracts, but in no event less than $ 100,000; or
2. An amount equal to the sum of eight percent of the annual health care expenditures (not including those expenditures paid on a capitated basis and those made on a managed hospital payment basis), as reported for the most recent four calendar quarters, plus four percent of the annual hospital expenditures paid on a managed hospital payment basis for the most recent four calendar quarters.
i. The amounts set forth in (a) above may be adjusted by the Commissioner to the extent the applicant demonstrates there is a limitation on its exposure to financial loss that results from a contract with a carrier that provides that any liabilities of the system may be satisfied by means of reductions or offsets against monies due to the system from the carrier, and which reductions or offsets the Commissioner finds will not adversely affect the system's ability to meet its contractual obligations.
ii. The minimum net worth requirements shall be phased-in over 48 months, so that an ODS shall maintain 25 percent of the minimum net worth required in (a) above at the end of the 12th month after it was issued a license; 50 percent of the minimum net worth required at the end of the 24th month following the month it was issued a license; 75 percent of the minimum net worth required at the end of the 36th month following the month it was issued a license; and 100 percent of the minimum net worth required at the end of the 48th month following the month it was issued a license.