N.J. Admin. Code § 11:24A-3.3

Current through Register Vol. 56, No. 19, October 7, 2024

Section 11:24A-3.3 - Designation of a medical director

(a) The carrier shall designate a physician licensed to practice medicine in New Jersey to serve as the medical director for the carrier with respect to its contracts or policies delivered in this State to which a utilization management program applies.

(b) The medical director shall be responsible for at least the following:

1. Overseeing the continuing in-service education of professional staff;

2. Providing clinical direction and leadership to the continuous quality improvement and utilization management programs;

3. Establishing policies and procedures covering all utilization management determination criteria and protocols applicable to health care services for which benefits are payable under a carrier's health benefits plans; and

4. Establishing policies and procedures covering all health care services provided to covered persons when the carrier is authorized, and elects, to engage in the direct or indirect provision of health care services.

N.J. Admin. Code § 11:24A-3.3