N.J. Admin. Code § 11:24-11.7

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24-11.7 - Reporting of compensation arrangements with health care providers involving incentive or disincentive programs

(a) In conjunction with the submission of the New Jersey--Specific Annual Supplement made in accordance with N.J.A.C. 11:24-11.6(c), every HMO shall submit aggregate reports on compensation arrangements between the HMO and providers under contract with the HMO (directly or through a secondary contractor) using the edition of HEDIS Table XIX (Primary Care Physician Payment Arrangement), Table XX (Specialist Payment Arrangement), and Table XXI (Mental Health Provider Payment Arrangement) for Medicaid in effect at the time of submission. Such tables are available from the National Commission on Quality Assurance, 1350 New York Avenue, Suite 700, Washington, DC 20005.

1. An HMO operating multiple lines of business (Medicaid, Medicare, and commercial, including any administrative service only business unless the health care providers have contracted with the self-funded arrangement) shall submit information separately for Medicaid, Medicare and commercial business if the HMO has different compensation arrangements for these lines of business.

(b) In conjunction with the submission of the New Jersey--Specific Annual Supplement made in accordance with N.J.A.C. 11:24-11.6(c), every HMO that uses financial incentive or disincentive arrangements in its compensation packages with providers under contract with the HMO (directly or through a secondary contractor) and/or utilization review organizations shall provide a certified explanation as to their accounting of the financial incentive or disincentive arrangements on the forms prescribed by the Commissioner completed in accordance with the instructions for those forms pursuant to N.J.A.C. 11:24-11.6(h).

1. The explanation shall be certified to by the Chief Financial Officer of the HMO.

N.J. Admin. Code § 11:24-11.7