N.J. Admin. Code § 11:22-1.4

Current through Register Vol. 56, No. 8, April 15, 2024

Section 11:22-1.4 - Claim submission requirements

(a) A health carrier or its agent shall provide in a clear and conspicuous manner through a publicly accessible internet website information concerning the submission and processing of claims including, but not limited to, where applicable:

1. A list of the material, documents, or other information required to be submitted to the health carrier or its agent with a claim for payment for health care services or supplies;

2. A description of claims for which the submission of additional documentation or information is required for the adjudication of a claim fitting that description, and an explanation of the additional information required;

3. The policy or procedure for reducing the payment for multiple services or supplies provided by a health care provider on the same date;

4. The policy for payment to assistant surgeons;

5. The policy for reimbursement for administration of immunization and injectable medications;

6. The policy regarding recognition of procedure modifiers;

7. Identification of the source of all commercially produced clinical criteria guidelines and a copy of all internally produced clinical criteria guidelines used by the health carrier or its agent to determine the medical necessity of health care services;

8. A street address where claim submissions can be delivered by hand or registered/certified mail if the claim is submitted by other than electronic means; and

9. The health carrier's application for a provider's internal appeal of a payment dispute.

(b) Health carriers or their agents may change the required information and documentation, as long as health care providers are given at least 30 days prior notice of the change in the requirements, which notice shall be made available on the carrier's internet website.

N.J. Admin. Code § 11:22-1.4

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