N.J. Admin. Code § 11:22-1.12

Current through Register Vol. 56, No. 9, May 6, 2024

Section 11:22-1.12 - External appeals-alternative payment dispute resolution-dental plan organizations and dental service corporations

(a) Every dental plan organization and dental service corporation shall offer an independent, external alternative payment dispute resolution (ADR) mechanism to participating health care providers to review adverse decisions of its internal appeals process.

1. The ADR mechanism shall be through an independent party. The costs of the process shall be borne equally by the parties. The recommended decision of the ADR mechanism shall be issued no later than 30 business days from receipt by the ADR firm of all documentation necessary to complete the review.

2 The ADR mechanism, including the method to submit a claim through such mechanism, shall be described in the participating provider contract and in the final internal decision denying or disputing the participating health care provider's claim, in full or in part.

3. The decision of the ADR mechanism shall be non-binding unless the parties agree otherwise.

(b) Dental plan organizations and dental service corporations shall annually notify participating providers in writing, or by posting on their websites, of the internal appeals process and the ADR mechanism and how they can be utilized.

(c) Dental plan organizations and dental service corporations shall annually report, in a format prescribed by the Department, the number of internal and external provider appeals received and how they were resolved.

N.J. Admin. Code § 11:22-1.12

Reserved by 50 N.J.R. 571(a), effective 1/16/2018

Adopted by 50 N.J.R. 829(a), effective 2/5/2018