N.J. Admin. Code § 11:22-3.8

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

Section 11:22-3.8 - Fraud prevention and detection

(a) All payers shall deploy as part of any system for the electronic receipt and transmission of claims an anti-fraud program, resident system and/or software that is approved by the Department's Division of Anti-Fraud Compliance.

(b) The anti-fraud system described in (a) above shall be capable, at a minimum, of the following activities:

1. Screening all claims, pre-payment and/or post-payment, for data patterns associated with fraudulent activity;

2. Responding to audit specific inquiries to facilitate fraud investigations;

3. Identifying phantom vendors, employees, patients and providers;

4. Identifying inappropriate or inconsistent charges; and

5. Scanning provider claims for unnecessary and repetitive charges.

(c) The anti-fraud efforts described in this section shall be made a part of and incorporated into a payer's fraud prevention and detection plan when required pursuant to N.J.A.C. 11:16-6, as applicable.

(d) Those payers not required to have a fraud prevention and detection plan under N.J.A.C. 11:16-6 shall file a description of the system required by this section with: New Jersey Department of Banking and Insurance

Division of Anti-Fraud Compliance

Attn: HINT/HIPAA-Fraud Prevention and Detection Plans

PO Box 324

20 West State Street

Trenton, NJ 08625-0324

(e) Payers shall comply with the requirements of 17:33A-1 et. seq. regarding the obligation to report suspected fraud to the New Jersey Office of Insurance Fraud Prosecutor.

N.J. Admin. Code § 11:22-3.8

Recodified from N.J.A.C. 11:22-3.10 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. 11:22-3.8, Use of clearinghouses in electronic transactions, recodified to N.J.A.C. 11:22-3.6.