N.J. Admin. Code § 11:10-1.4

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:10-1.4 - General rules

(a) Any person desiring to establish, operate or administer a dental plan organization shall apply to the Commissioner for a certificate of authority. An application for a certificate of authority as a dental plan organization is available on the Department's website at www.state.nj.us/dobi/division_insurance/managedcare/dpo_app.pdf or can be obtained from:

New Jersey Department of Banking and Insurance

Valuation Bureau

Life and Health Division

20 West State Street

PO Box 325

Trenton, NJ 08625-0325

Phone: 609-292-5427

(b) Following the issuance of a Certificate of Authority, the DPO shall notify the Department in writing 60 days prior to any significant modification of information submitted with the application, or subsequently submitted, and shall include the document being modified and an explanation of the modification. Examples of modifications which are considered significant include, but are not limited to:

1. Changes in the DPO's organizational structure;

2. New officers, partners or members of the DPO's board of directors, board of trustees, executive committee or other governing board or committee;

3. Changes in the group or individual contract form issued by the DPO;

4. Adjustments to financial statements;

5. A change in ownership; and

6. Changes to provider agreements.

(c) No DPO shall use a specialist pool unless it is filed with the Department for approval. The specialist pool filing shall be deemed approved upon the expiration of 30 days after it is filed unless disapproved in writing by the Commissioner within that time. All specialist pools shall comply with the following requirements:

1. A specialist pool may exist only when the specialists contract with the DPO to serve as participating dentists, but are not employees of the DPO;

2. The procedures for which specialists are responsible, and which are not provided by primary dentists, shall be identified in the contract between the specialist and the DPO. The contract shall be included in the request for approval submitted to the Department;

3. The specialist shall be paid on a contractual fee schedule basis. The contractual fee schedule shall be included in the specialist contract filed pursuant to 11:10-1.5, and in the request for approval filed with the Commissioner;

4. The schedule of charges filed pursuant to 11:10-1.1 2 shall identify, by plan, the proportion of the charges attributable to the specialist services, and shall be included in the request for approval filed with the Commissioner;

5. After addition of the charges and deductions for payments to specialists, any excess in the specialist pool shall be paid on an annual basis to the primary dentists and shall not be retained by the DPO. The method by which payment of the excess is to be made to the dentists shall be included with the request for approval filed with the Commissioner. Any changes in the methodology shall be filed with the Commissioner before its use;

6. The DPO shall be responsible for all payments for services provided by specialists. Payments shall be made from the specialist pool until all funds are depleted, and thereafter payments shall be made from the DPO's general funds; and

7. In conjunction with the filing of the annual report required by 11:10-1.7, each DPO having an approved specialist pool shall submit a separate financial accounting of the specialist pool for the preceding calendar year. The report shall set forth, by plan, the contributions to the pool, the payments made to specialists from the pool and the resulting excess or deficit. If an excess exists, the report shall indicate when the distribution of the excess will be made and whether the method of distribution remains unchanged from that originally filed with the Department.

(d) A DPO shall file for approval with the Department an alternative payment methodology prior to use. The alternative payment methodology shall be deemed approved 30 days after filing unless disapproved in writing by the Commissioner within that timeframe. All alternative payment methodologies shall include the following:

1. A clear explanation of the methodology and numerical examples illustrating how the methodology will operate; and

2. An explanation of the appropriateness of the payment methodology to recruit new dentists, retain contracted dentists in underserved areas and/or eliminate disincentives for contracted dentists to render quality dental care to covered persons of the DPO.

(e) Three copies of a request for approval of a specialist pool or alternative payment methodology shall be submitted to the Department at the following address:

Chief Actuary

Office of Life and Health

New Jersey Department of Banking and Insurance

20 West State Street

PO Box 325

Trenton, NJ 08625-0325

(f) Every DPO shall report to the Commissioner the name and address of, and the amount of any fee paid to, a finder within 30 days of the use or employment of the finder.

(g) A DPO that has not had its certificate of authority suspended or revoked shall automatically renew each year while in compliance with this subchapter.

N.J. Admin. Code § 11:10-1.4

Amended by R.1991 d.303, effective 6/17/1991 (operative July 1, 1991).
See: 23 N.J.R. 825(a), 23 N.J.R. 1948(a).
Deleted "$ 100.00"; added "as set forth in N.J.A.C. 11:1-32.4(a)7" in (b).
Amended by R.1994 d.200, effective 4/18/1994.
See: 26 N.J.R. 738(a), 26 N.J.R. 1661(a).
Amended by R.2011 d.227, effective 9/6/2011.
See: 43 N.J.R. 124(a), 43 N.J.R. 2347(a).
Rewrote the section.