17B:30-55.13 Payer shall not deny reimbursement, hospital, health care provider in compliance, circumstances,
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/nj/title-17b/chapter-30/17b-30-55-13·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
14. a. When a hospital or health care provider complies with the provisions set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.), no payer shall deny reimbursement to a hospital or health care provider for covered services rendered to a covered person on grounds of failure to secure prior or concurrent authorization in the absence of fraud or misrepresentation if the hospital or health care provider:
(1)requested authorization from the payer and received approval for the health care services delivered prior to rendering the service;
(2)requested authorization from the payer for the health care services prior to rendering the services and the payer failed to respond to the hospital or health care provider within the time frames established pursuant to P.L.2023, c.296 (C.17B:30-55.1 et al.); or
(3)received authorization for the covered service for a patient who is no longer eligible to receive coverage from that payer and it is determined that the patient is covered by another payer, in which case the subsequent payer, based on the subsequent payer's benefits plan, shall accept the authorization and reimburse the hospital or health care provider.
b. If the hospital is a network provider of the payer, health care services shall be reimbursed at the contracted rate for the services provided.
c. No payer shall amend a claim by changing the diagnostic code assigned to the services rendered by a hospital or health care provider without providing written justification.
L.2023, c.296, s.14.