N.J. Admin. Code § 11:22-3.4

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

Section 11:22-3.4 - Health care providers; claims

(a) On or after October 1, 2002, all payers shall require that all providers file all claims for payment unless the patient, at his or her option, files the claim directly.

(b) Where a claim is being filed by the health care provider on behalf of the patient without an assignment of benefits, the provider shall file the claim within 60 days of the last date of service of that course of treatment.

(c) Where the provider is filing a claim under an assignment of benefits from the patient, the provider shall file the claim within 180 days of the last date of service of the course of treatment.

(d) In the event a health care provider does not file the claim within 180 days of the last date of service of a course of treatment referred to in (c) above, the third party payer and/or health benefit payer shall in accordance with 11:22-1.6 reserve the right to deny or dispute the claim and the health care provider shall be prohibited from seeking payment in whole or in part directly from the patient.

(e) When a health benefit payer takes action in accordance with (d) above, the health benefit payer shall advise the health care provider that payment of the claim, in whole or in part, will be made based upon consideration of the following factors that shall be addressed by the provider:

1. The good faith use of information provided by the patient to the health care provider with respect to the identity of the patient's health benefits payer;

2. Delays encountered in filing a claim related to the coordination of benefits among third party payers;

3. Whether the health care provider has previously filed untimely claims or has an established pattern of untimely claim practices;

4. Any prejudice to the rights of the patient and/or the health benefits provider in determination of the medical necessity of the services and care being billed for; and

5. Potential adverse impact to the public.

(f) Providers failing to file a claim within 180 days in accordance with (d) above whose claim for payment has been denied in whole or in part may, in the discretion of a Judge of the Superior Court, be permitted to refile the claim where there has not been substantial prejudice to the health benefit payer. Application to the Superior Court for permission to refile a claim shall be made within 14 days of the notification of denial of payment and shall be made upon motion based upon affidavit(s) showing sufficient reason(s) for the failure to file the claim with the third party payer within the required time.

N.J. Admin. Code § 11:22-3.4

Recodified from N.J.A.C. 11:22-3.6 by R.2011 d.256, effective 10/17/2011.
See: 43 N.J.R. 1236(a), 43 N.J.R. 2668(b).
Former N.J.A.C. 11:22-3.4, Timetable and operational status reports, repealed.