N.J. Admin. Code § 11:22-1.6

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

Section 11:22-1.6 - Denied and disputed claims

(a) A carrier or its agent shall either deny or dispute a claim, in full or in part, that has not been processed according to 11:22-1.5. If only a portion of a claim is disputed or denied, the carrier or its agent shall remit payment for the uncontested portion in accordance with 11:22-1.5. A carrier's or its agent's characterization of a claim as pending shall not release the carrier of its obligation to either deny or dispute a claim in accordance with this section. The carrier or its agent shall, within 30 or 40 calendar days of receipt of the claim, whichever is applicable, notify the covered person, when he or she will have increased responsibility for payment, and the provider of the basis for its decision to deny or dispute, including:

1. The identification and explanation of all reasons why the claim was denied or disputed;

i. A carrier or its agent shall not deny or dispute a claim for reasons other than those identified in the first review after the claim is entered, unless information or documentation relevant to the claim is received after the first review and such documentation leads to additional reasons to deny or dispute which were not present at the time of that review.

2. If the claim is incomplete, the notice shall include a statement specifically identifying the substantiating documentation or other information that is required for adjudication of the claim.

3. If the diagnosis coding, procedure coding, or any other required information required to be submitted with the claim is incorrect, the notice shall include a statement specifically identifying the information that must be corrected for adjudication of the claim;

4. If the carrier or its agent disputes the amount of the claim in whole or in part, the notice shall include a statement of the basis for that dispute, including any change of coding performed by the carrier and the reasons for such change of coding;

5. If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding, or any other data required to be submitted with the claim was missing, the carrier or its agent shall electronically notify the health care provider or its agent, within seven days of its determination that the claim is missing required information, and request any information required to complete adjudication of the claim. If the missing information is subsequently submitted, the carrier or its agent shall process the claim in accordance with 11:22-1.5 and this section.

6. If the health carrier or its agent finds there is strong evidence of fraud by the provider and has initiated an investigation into the suspected fraud, the notice shall state that the health carrier or its agent finds that there is strong evidence of fraud and, if applicable, that it has initiated an investigation into the suspected fraud in accordance with its fraud prevention plan established pursuant to 17:33A-15, and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety and the Bureau of Fraud Deterrence in the Department pursuant to 17:33A-9.

7. The notice shall include the toll-free telephone number through which the carrier or its agent can be contacted by the provider or covered person to discuss the claim.

(b) If a carrier or its agent denies or disputes a claim in whole or in part and fails to provide the notice required by (a) above, within the timeframes and in the manner required of carriers that are subject to P.L. 2005, c. 352 the claim shall be deemed to be overdue.

(c) If a carrier or its agent subject to the provisions of 17:33A-1 et seq., has reason to believe that the claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to 17:33A-15 and, if applicable, refer the claim to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety and the Bureau of Fraud Deterrence in the Department.

(d) Unless otherwise provided by law, every carrier or its agent shall pay the amount finally agreed upon in settlement of all or part of any claim not later than 10 working days from either the receipt of such agreement by the carrier or the date the performance by the covered person or the provider of any conditions to payment set forth in the agreement, whichever is later.

N.J. Admin. Code § 11:22-1.6

Amended and recodified from 11:22-1.7 by 50 N.J.R. 571(a), effective 1/16/2018

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