N.J. Admin. Code § 11:16-6.9

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:16-6.9 - Approval and filing of fraud prevention and detection plans

(a) An insurer's fraud prevention and detection plan shall be deemed approved by the Commissioner if not affirmatively approved or disapproved by the Commissioner within 90 days of the date of filing.

(b) The Commissioner may request such amendments to the plan as he or she deems necessary.

(c) An insurer must submit amendments to its plan when necessary to achieve compliance with these rules. Any amendments to a plan filed with the Commissioner shall be deemed approved by the Commissioner if not affirmatively approved or disapproved within 90 days of the date of filing.

(d) The insurer shall permit the MCEAFC access to its offices upon reasonable notice and at reasonable hours to conduct an audit of the insurer's compliance with its fraud prevention plan. Nothing in this section shall be construed as to preclude the MCEAFC from conducting reviews of an insurer's compliance with its fraud prevention and detection plan at the office of the MCEAFC when determined to be necessary by the MCEAFC.

(e) In those instances in which an insurer uses an outside agent, third party administrator or contractor to perform SIU functions or claims investigations, the Plan and contract with the outside vendor or third party administrator shall provide that the Department shall be permitted to audit the records, books, and documents maintained by the outside contractor or third party administrator in the same manner and fashion as it would be able to examine the books and records in accordance with N.J.S.A. 17:33A-15 and N.J.S.A. 17:23-22.

(f) All information included in an insurer's plan submitted to the MCEAFC pursuant to this subchapter including, but not limited to, training programs submitted to MCEAFC pursuant to this subchapter, shall be confidential and not subject to public disclosure or inspection.

N.J. Admin. Code § 11:16-6.9

Amended by R.2005 d.159, effective 5/16/2005.
See: 37 New Jersey Register 199(a), 37 New Jersey Register 1733(a).
Substituted "MCEAFC" for "DAFC" throughout.