N.J. Admin. Code § 11:24A-3.4

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

Section 11:24A-3.4 - Utilization management program

(a) A carrier's UM program shall be under the direction of the medical director, or his or her designee (who shall be a physician licensed to practice medicine in the State of New Jersey), and shall be based on a written plan, reviewed annually by the carrier, and available for review by the Department upon request, specifying at least:

1. The scope of the carrier's UM activities;

2. The procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;

3. The mechanisms to detect underutilization and over utilization of services;

4. The clinical review criteria and protocols used in decision-making;

5. The mechanisms to ensure consistent application of review criteria and uniform decisions;

6. The development of measures for evaluating the carrier's UM program, including outcome and process measures when the carrier utilizes a gatekeeper system or practice guidelines for its managed care product(s);

7. A system for covered persons, and providers on behalf of covered persons (with the covered person's consent) to appeal UM determinations in accordance with the procedures set forth at 11:24A-3.5; and

8. A mechanism to evaluate the satisfaction of covered persons with the appeals system, which mechanism shall coordinate with the carrier's CQI program required pursuant to 11:24A-3.8.

(b) Carriers shall ensure that UM determinations are based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers and based upon generally accepted medical standards.

1. The carrier shall periodically review (no less than annually) and update these criteria as necessary.

2. The carrier shall make the criteria readily available, upon request, to covered persons and interested providers except that internal or proprietary quantitative thresholds for UM is not required to be released to covered persons or providers pursuant to this subchapter.

i. When the request is related to specific treatment or services for which benefits are being sought, the information provided may be limited to all criteria and protocols by which the carrier performs UM relevant to only that treatment or services.

(c) The carrier shall provide access to UM services as follows:

1. For routine utilization-related inquiries, covered persons and providers shall have access to UM staff on, at a minimum, a five-day, 40 hours a week basis through a toll-free telephone number.

(d) The carrier shall have written policies and procedures, available for review by the Department upon request, that address the responsibilities and qualifications of staff who render determinations to authorize admissions, services, procedures or extensions of stay meeting the following:

1. All determinations to deny or limit an admission, service, procedure or extension of stay, or benefits therefor, shall be made in accordance with the clinical and medical necessity criteria developed in accordance with (b) above, and rendered by a physician under the clinical direction of the medical director required pursuant to 11:24A-3.3.

i. The physician shall communicate the determination directly to the provider or, if this is not possible, the physician shall supply his or her name, telephone number and where he or she may be reached so that the provider may contact the physician for further discussion.

ii. The physician rendering the determination shall be available immediately to the treating provider in urgent or emergency cases and on a timely basis for all other cases as required by the medical exigencies of the situation;

2. All determinations shall be made on a timely basis, as required by the exigencies of the situation; and

3. A carrier shall notify a provider and/or covered person of a determination concerning an urgent care claim and determined by the attending provider as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the urgent care claim by the carrier, of a determination concerning a non-urgent pre-service claim (that is, prior authorization) no later than 15 days after receipt of the pre-service claim by the carrier, and of a determination concerning post-service claims no later than 30 days after receipt of the post-service claim by the carrier.

(e) A carrier shall not reverse a utilization management decision where the provider relied upon the written or oral authorization of the carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud.

(f) A carrier shall provide written notice within two business days of any determination to deny coverage or authorization of services or payment of benefits therefor otherwise covered under the contract or policy of the covered person, and shall include an explanation of the appeal process.

N.J. Admin. Code § 11:24A-3.4

Amended by R.2011 d.097, effective 4/4/2011.
See: 42 N.J.R. 2920(a), 43 N.J.R. 880(a).
Deleted (c)2.
Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
In (d)1ii, substituted a semicolon for a period at the end; in (d)2, substituted "; and" for a period at the end; added (d)3; in (e), substituted "reverse a utilization management decision where the provider" for "deny reimbursement retroactively for a covered service provided to a covered person by a provider who"; and in (f), substituted "two business days" for "five days, or sooner if the medical exigencies dictate, upon request,".