N.J. Admin. Code § 11:23-4.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 11:23-4.1 - Suspension or revocation of license; grounds and penalties

(a) The Commissioner may suspend or revoke a license or registration issued pursuant to the Act if he or she finds that the third party administrator:

1. Is in an unsound financial condition;

2. Is using methods or practices in the conduct of its business that render its further transaction of business in this State hazardous or injurious to the benefits payers with which it has contracted or the public;

3. Has failed to pay any judgment rendered against it in this State within 60 days after the judgment has become final;

4. Has violated any lawful rule or order of the Commissioner or any provision of State law;

5. Has refused to be examined or to produce its accounts, records and files for examination, or if any of its officers have refused to supply information with respect to its affairs, or has refused to perform any other legal obligation as to an examination, when required by the Commissioner;

6. Has, without just cause, refused or failed to pay proper claims or perform services arising under its contracts;

7. At any time fails to meet any requirement, on the basis of which issuance of the initial license could have been refused had that failure then existed and been known to the Commissioner;

8. Has been convicted of, or has entered a plea of guilty or nolo contendere to a felony or crime of the first, second or third degree in this State, without regard to whether adjudication was withheld;

9. Has had a credential as a third party administrator suspended, revoked or non-renewed for cause in another state;

10. Has willfully reimbursed enrollees for benefits not eligible under the benefits payer's benefits plan;

11. Has provided false or inaccurate information in the certification provided with an initial application for licensure or registration pursuant to N.J.A.C. 11:23-2.2(a) or in any other submission to the Department; or

12. Has contracted with or on behalf of a self-funded multiple employer welfare arrangement (MEWA) which is not registered pursuant to N.J.S.A. 17B:27C-1 et seq.

(b) If the Commissioner finds that one or more grounds exist for the suspension or revocation of a license or registration issued under the Act, the Commissioner may, in lieu of or in addition to suspension or revocation, impose a fine upon the administrator.

N.J. Admin. Code § 11:23-4.1