N.J. Admin. Code § 11:24-4.2

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

Section 11:24-4.2 - Medical director' responsibility

(a) The medical director shall be responsible for the direction, provision, and quality of medical services provided to members, including, but not limited to:

1. Defining responsibilities and inter-relationships of professional services;

2. Coordinating, supervising and overseeing the functioning of professional services;

3. Evaluating the medical aspects of provider contracts;

4. Overseeing the continuing in-service education of professional staff;

5. Providing clinical direction and leadership to the continuous quality improvement and utilization management programs;

6. Establishing policies and procedures covering all health care services provided to members;

7. Establishing a committee that has the following responsibilities:

i. Establishing mechanisms for ensuring review of provider credentials;

ii. Delineating qualifications of participating providers;

iii. Reviewing credentials of physicians and other providers who do not meet the HMO's established credentialing standards; and

iv. Establishing a system for verification of provider's credentials, recertification, performance reviews and obtaining information about any disciplinary action against the provider available from the New Jersey Board of Medical Examiners or any other state licensing board applicable to the provider, or the Federal Clearinghouse established pursuant to the Health Care Quality Improvement Act, P.L. 99-660 ( 42 U.S.C. § 1101 et seq.);

8. Implementing a procedure that provides participating providers an opportunity to review and comment on all applicable medical, surgical and dental protocols of the HMO applicable to the area of practice of the provider; and

9. Implementing a system through which a member may readily change his or her PCP outside of an annual open enrollment period, and is made aware of this right, which system shall be applicable to all of the HMO's contracts including its POS contracts, regardless of whether referral through the PCP is required in order to access specialty care in-network or to receive benefits out-of-network.

i. An HMO shall make the selection of a new PCP effective no later than 14 days following the date of the selection when such change is discretionary, and shall make the selection of a new provider immediately effective when change of the PCP is necessitated by termination of the PCP from the network.

N.J. Admin. Code § 11:24-4.2

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
In (a), added 8 and 9.