N.J. Admin. Code § 11:24A-5.2

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

Section 11:24A-5.2 - Department review of carrier actions on IURO recommendations

(a) The Department shall periodically review records of carrier reports submitted pursuant to N.J.A.C. 11:24A-3.7 to determine whether a carrier exhibits a pattern of noncompliance with the recommendations of an IURO as well as possible violations of patient rights or other applicable laws.

(b) If the Department determines that a carrier exhibits a pattern of noncompliance with the recommendations of an IURO, the Department shall review:

1. Whether the carrier's noncompliance is with a specific set of recommendations;

2. Whether the carrier's noncompliance is with a specific IURO (in the event more than one IURO participates in the Independent Health Care Appeals Program); and

3. The carrier's utilization management program, if any.

(c) If the Department determines that the carrier's utilization management program is not in compliance with the utilization management standards set forth at N.J.A.C. 11:24A-3.4 and 4.11, as applicable, or other relevant laws, the Department take action(s) as deemed appropriate, in the discretion of the Commissioner, if any, pursuant to N.J.A.C. 11:24A-2.7.

(d) If the Department determines that the carrier is in violation of patient rights or other applicable regulations, the Department shall take action(s) as deemed appropriate, in the discretion of the Commissioner, if any, pursuant to N.J.A.C. 11:24A-2.7.

(e) A pattern of noncompliance shall mean the occurrence of multiple incidents of refusal to follow the recommendations of the IURO, in whole or in part, within a 12 month period, when such recommendations require the carrier to provide services or benefits therefor to a covered person.

N.J. Admin. Code § 11:24A-5.2