17B:30-55.4 Payer, information, utilization management, processing, payment of claims.
351 words·~2 min read·
/nj/title-17b/chapter-30/17b-30-55-4·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
5. a. A payer shall provide the following information concerning utilization management and the processing and payment of claims in a clear and conspicuous manner, described in detail but also in easily understandable language, to covered persons, health care providers, and the general public, through an Internet website no later than 30 calendar days before the information or policies or any changes in the information or policies take effect:
(1)a description of the source of all commercially produced clinical criteria guidelines and a copy of all internally produced clinical criteria guidelines used by the payer or its agent to determine the medical necessity of health care services;
(2)a list of the material, documents, or other information required to be submitted to the payer with a claim for payment for health care services;
(3)a description of the type of claims for which the submission of additional documentation or information is required for the adjudication of a claim fitting that description;
(4)the payer's policy or procedure for reducing the payment for a duplicate or subsequent service provided by a health care provider on the same date of service;
(5)prescription drug formularies; and
(6)any other information the commissioner deems necessary.
b. Any changes in the information or policies required to be provided pursuant to subsection a. of this section shall be clearly noted on the Internet website.
c. A payer shall, for health care services as defined pursuant to section 4 of P.L.2023, c.296 (C.17B:30-55.3) but excluding the provision of pharmaceutical products:
(1)provide impacted contracted in-network health care providers with written notice of any new or materially adverse amended requirement or restriction no less than 90 days before the requirement or restriction is implemented;
(2)ensure that any new or amended requirement is not implemented unless the payer's Internet website has been updated to reflect the new or amended requirement or restriction; and
(3)withhold implementation of any new materially adverse requirement or restriction until and unless 90 days have passed since written notice was provided to an impacted contracted in-network health care provider.
L.2023, c.296, s.5.