N.J. Admin. Code § 11:24-2.3

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

Section 11:24-2.3 - Issuance of a certificate of authority

(a) A certificate of authority to establish and operate an HMO to service commercial enrollees shall be issued upon approval of the Commissioner.

(b) A certificate of authority to establish and operate an HMO to service both Medicaid and commercial enrollees shall not be approved for purposes of serving Medicaid enrollees until such time that the Commissioner has received and considered the recommendation of the Department of Human Services, Division of Medical Assistance and Health Services on the applicant's compliance with the State and Federal requirements of a contract between the applicant and the Department of Human Services.

(c) Issuance of a certificate of authority shall be granted upon demonstration of compliance, to the satisfaction of the Commissioner, with these rules and the requirements in N.J.S.A. 26:2J-1 et seq.

(d) Prior to issuance of a certificate of authority, a preoperational audit shall be conducted by the Departments of Banking and Insurance and/or Human Services to evaluate the HMO's ability to perform essential functions including, but not limited to, claims processing, utilization management and quality assurance protocols, adequacy of accounting and information systems, operational and financial controls, and network adequacy. The applicant shall bear all reasonable costs associated with conducting the preoperational audit, including, but not limited to, outside consultant and subcontractor fees.

N.J. Admin. Code § 11:24-2.3

Amended by R.1999 d.201, effective 6/21/1999.
See: 31 N.J.R. 610(a), 31 N.J.R. 1631(a).
Rewrote (d).