N.J. Admin. Code § 11:3-4.8

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

Section 11:3-4.8 - Voluntary networks

(a) No insurer shall file a decision point review plan utilizing a voluntary network or networks unless the network is a health maintenance organization licensed pursuant to 26:2J-1 et seq.; or approved by the Department as part of a selective contracting arrangement with a health benefits plan pursuant to N.J.A.C. 11:4-37 and 11:24A-4.1 0; or approved as part of a workers' compensation managed care organization pursuant to N.J.A.C. 11:6; or is licensed or certified as an organized delivery system pursuant to N.J.A.C. 11:22-4 and 11:24B.

(b) Voluntary networks may be offered for the provision of the following types of non-emergency benefits only:

1. Magnetic Resonance Imagery;

2. Computer Assisted Tomography;

3. The electrodiagnostic tests listed in 11:3-4.5(b)1 through 3 except for needle EMGs, H-reflex and nerve conduction velocity (NCV) tests performed together by the treating physician;

4. Durable medical equipment with a cost or monthly rental in excess of $ 50.00;

5. Prescription drugs; or

6. Services, equipment or accommodations provided by an ambulatory surgery facility.

(c) Insurers that offer voluntary networks either directly or through a PIP vendor shall meet the following requirements:

1. The insurer shall notify all insureds upon application for and issuance of the policy and upon renewal of the types of benefits for which it has voluntary networks. Use of the network by the insured is voluntary but bills for out-of-network services or equipment are subject to the penalty deductibles set forth in 11:3-4.4(g).

2. Upon receipt of a request for PIP benefits under the policy, the insurer or its PIP vendor shall make available to the insured and the treating medical provider information about approved networks and providers in the network, including addresses and telephone numbers. Insureds shall be able to choose to go to any provider in the network.

(d) An insurer offering a voluntary network or networks directly or through a PIP vendor shall submit the following information to the Department with its Decision Point Review Plan:

1. A narrative description of the benefits to be offered through the network or networks;

2. The identity and a description of the network and the specific services or supplies to be provided by the network or networks;

3. A description of the procedures by which benefits may be obtained by persons using the network; and

4. A statement of how the network meets the requirement of (a) above.

(e) Any voluntary network used by an insurer pursuant to this subchapter shall agree to disclose to a participating provider, upon written request, a list of all the clients or other payers that are entitled to a specific rate under the network's contract with the participating provider.

N.J. Admin. Code § 11:3-4.8

Amended by R.2000 d.454, effective 11/6/2000.
See: 31 N.J.R. 4210(a), 32 N.J.R. 4005(c).
Rewrote the section.
Repeal and New Rule, R.2004 d.218, effective 6/7/2004 (operative October 27, 2004).
See: 35 N.J.R. 3072(a), 36 N.J.R. 2890(a), 36 N.J.R. 4319(a).
Section was "Precertification".
Amended by R.2010 d.142, effective 7/6/2010.
See: 41 N.J.R. 2609(a), 42 N.J.R. 1385(a).
In (a), substituted "11:24A" for "8:38A", substituted a semicolon for a comma following "11.6", and substituted "11:24B" for "8:38B"; in (b)4, deleted "or" from the end; in (b)5, substituted "; or" for a period at the end; added (b)6; and in (c)1, updated the N.J.A.C. reference.
Administrative correction.
See: 42 N.J.R. 2129(a).
Amended by R.2012 d.187, effective 11/5/2012 (operative January 4, 2013).
See: 43 N.J.R. 1640(a), 44 N.J.R. 2652(c).
In (b)3, inserted ", H-reflex and nerve conduction velocity (NCV) tests" and "together".