N.J. Admin. Code § 11:24-8.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24-8.3 - Utilization management determinations

(a) The HMO shall have written policies and procedures that address responsibilities and qualifications of staff who render determinations to authorize admissions, services, procedures or extensions of stay.

(b) All determinations to deny or limit an admission, service, procedure or extension of stay shall be rendered by a physician. The determination shall be directly communicated by the physician to the provider or, if this is not possible, the provider shall be supplied with the physician's name, telephone number, and where he or she can be reached. The physician shall be available immediately in urgent or emergency cases and on a timely basis for all other cases as required by the medical exigencies of the situation. The physician shall be under the clinical direction of the medical director responsible for medical services provided to the HMO's New Jersey members. Such determinations shall be made in accordance with clinical and medical necessity criteria developed pursuant to 11:24-8.1(b) and the evidence of coverage.

(c) All determinations shall be made on a timely basis, as required by the exigencies of the situation.

1. An HMO shall notify a provider and/or member of a determination concerning:

i. An urgent care claim and determination by the attending provider as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the urgent care claim by the HMO;

ii. A non-urgent pre-service (that is, prior authorization) no later than 15 days after receipt of the pre-service claim by the HMO; and

iii. A determination concerning a post-service claim no later than 30 days after receipt of the post-service claim by the HMO.

(d) An HMO shall not reverse a utilization management decision where the provider relied upon the written or oral authorization of the HMO or its agents prior to providing the service to the member, except in cases where there was material misrepresentation or fraud.

(e) A member or provider acting on behalf of a member shall receive written notice of any determination to deny coverage or authorization for services required in this subchapter or in the evidence of coverage, which shall be subject to appeal in accordance with 11:24-8.5, 8.6 and 8.7, within two business days of the determination. The written notice of determination shall include an explanation of the appeal process.

N.J. Admin. Code § 11:24-8.3

Petition for Rulemaking.
See: 32 N.J.R. 3340(a).
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Added (c)1; rewrote (d); and in (e), deleted "upon request a" following "receive" and inserted ", within two business days of the determination".