N.J. Admin. Code § 11:24B-2.4

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

Section 11:24B-2.4 - CODS: Part B of the application for certification

(a) An ODS shall specify the services it will deliver on behalf of one or more carriers under contract, by category, as follows:

1. Performing or arranging for the performance of one or more types of health care services;

2. Network management, including recruitment and retention;

3. Credentialing and recredentialing;

4. Utilization management development;

5. Utilization management application;

6. Utilization management appeals;

7. Member complaints;

8. Provider complaints; and

9. Continuous quality improvement.

(b) The categories of delivery of services set forth in (a) above are not necessarily mutually exclusive.

1. An ODS that delivers network management services shall be delivering the categories of services in (a)1, 3, 8 and 9 above as well with respect to the ODS' network, but shall only be required to specify network management and pay the fee therefor at N.J.A.C. 11:24B-2.9, so long as no other category of services are provided with respect to any other providers or networks outside of the ODS' network for one or more carriers.

2. If an ODS delivering network management services also performs one of the categories of services in (a)4, 5, 6 and 7 above, whether or not performance is limited to the ODS' network, the ODS shall specify the additional service(s) and the additional fee(s) therefor at N.J.A.C. 11:24B-2.9.

3. All ODSs that deliver the categories of services set forth at (a)2 through 9 above shall also be delivering services pursuant to (a)1 above, but shall only be required to specify the performance of the services at (a)2 through 9 above, as appropriate, and pay the fees therefor set forth at N.J.A.C. 11:24B-2.9.

4. An ODS may solely deliver the performance of health care services (that is, the category in (a)1 above), and shall specify this and pay the fee at N.J.A.C. 11:24B-2.9 accordingly, if that is the case.

(c) An ODS that is performing or arranging for the performance of health care services shall provide the following:

1. A list setting forth the names of all providers under contract with the ODS by county, municipality and zip code, accompanied by maps of the service area identifying the location of the participating providers by address.

i. The list shall set forth the separate names of each hospital, health care professional and ancillary provider contracted directly with the ODS, or contracted through another entity.

ii. The list shall specify whether any of the health care providers are affiliates of the ODS.

iii. The list shall specify the types of health care services that the ODS has agreed to have performed under contract with the carrier(s);

2. The criteria that the ODS will use to assure the availability and accessibility of the services to be performed, including a description and flow chart of how emergency or urgent medical services will be available 24 hours a day, seven days a week; and

3. A completed set of tables, which shall indicate the number of providers, general acute care hospitals, and ancillary, tertiary and specialized providers, which can be found on the Department's website: www.state.nj.us/dobi/formlist.htm.

(d) An ODS that is engaging in network management on behalf of a carrier shall submit the information set forth in (c)1 above, in addition to the following:

1. The criteria that the ODS shall use to assure the availability and accessibility of the services it will provide or arrange to provide, including, but not limited, to a demonstration of the adequacy of the number of actual providers of specific health care services that the ODS proposes to provide or arrange for the provision of in relation to the number of covered persons the ODS projects it will be servicing, which demonstration shall be consistent with the standards of N.J.A.C. 11:24B-3.5;

2. An explanation of the continuous quality improvement program(s) the ODS shall use, consistent with the requirements of (k) below;

3. An explanation of the ODS' complaint and appeal system established for providers consistent with the requirements of (j) below.

4. An explanation of the ODS' provider participation panel, consistent with the standards of N.J.A.C. 8:38-3.9 or 8:38A-4.7, as appropriate;

5. An explanation of the ODS' hearing panel for provider termination actions consistent with the standards of N.J.A.C. 8:38-3.6 or 8:38A-4.9, as appropriate;

6. An explanation of the ODS' procedures for maintenance of records that include any information regarding the covered persons of carriers, and the criteria and process the ODS will use to maintain confidentiality of such information.

i. The ODS shall include an explanation of how a covered person may obtain information maintained by the ODS and contracted health care providers on the covered person at a cost that shall not in any event exceed costs established for release of hospital records.

ii. The ODS shall include an explanation of how the carrier may access the information maintained by the ODS and contracted health care providers on the covered person; and

7. The ODS' credentialing and recredentialing standards and procedures, if any, consistent with the requirements of (e) below.

(e) If an ODS is engaging in credentialing and recredentialing, the ODS shall submit the following information:

1. A copy of the ODS' policies and procedures regarding the process and standards for credentialing, consistent with the requirements of N.J.A.C. 11:24B-3.6.

i. The policies and procedures shall demonstrate the status of the medical director with oversight of the credentialing program, including both his or her licensure status, organizational affiliation(s) (for example, is the medical director employed by the ODS or employed by the carrier), and the level of involvement of the medical director in the credentialing and recredentialing process;

2. The name of the medical director licensed to practice in New Jersey; and

3. A detailed explanation of how the ODS' functions are linked and coordinated with each of the contracted carriers' continuous quality improvement and complaint systems (or those of the carriers' other contractors, as appropriate), as required by N.J.A.C. 11:24B-3.6(a)6.

i. The detailed explanation shall include an outline of the organizational structures within the ODS and the carriers (and their contractors) that will communicate regarding the credentialing process, and the flow chart for such communication relative to both positive and negative credentialing or recredentialing outcomes, including the process for the ODS to react to requests for information regarding a specific health care professional pursuant to an inquiry or complaint.

(f) An ODS that is engaging in utilization management development shall submit the following information:

1. The ODS' policies and procedures setting forth the standards for development of protocols and guidelines, and demonstrating that its practices and procedures are consistent with N.J.A.C. 11:24B-3.7;

2. The name of the medical director(s) licensed to practice in New Jersey having oversight of the mechanism by which each carrier's participating providers may review and comment on protocols, whether he or she is employed by the ODS or the carrier(s), and if employed by the carriers, the method and degree of involvement that the medical director has with respect to protocol development, and method of assuring that comments of a carrier's participating providers are considered. The ODS shall include a descriptive flow chart of the process; and

3. A copy of the protocols and guidelines developed, including any instructions on use and deviations from the protocols established.

(g) An ODS that is performing utilization management shall submit the following information:

1. The ODS' policies and procedures for utilization management, which shall demonstrate that the ODS is performing utilization management consistent with the standards of N.J.A.C. 11:24B-3.8. The ODS shall include a descriptive flow chart of the process;

2. The name of the medical director with oversight of the ODS' utilization management, a statement as to whether he or she is employed by the ODS or by the carrier(s), and if employed by a carrier, a detailed explanation of how the medical director provides oversight of the utilization management program of the ODS; and

3. An explanation of what utilization management criteria the ODS uses in making utilization management determinations, and how the utilization management criteria are generated.

(h) An ODS that engages in one or both stages of the utilization management appeal process shall submit the following information:

1. The ODS' policies and procedures for the utilization management appeals process, which shall demonstrate that the ODS is processing and reviewing appeals consistent with the standards of N.J.A.C. 11:24B-3.9;

2. The name of the medical director with oversight of the ODS' utilization management appeal process, a statement as to whether he or she is employed by the ODS or by the carrier(s), and if employed by a carrier, a detailed explanation of how the medical director provides oversight of the utilization management program of the ODS, including a flow chart demonstrating the manner in which decisions are made and communicated between the ODS and the medical director;

3. An explanation of what utilization management criteria the ODS uses in making utilization management determinations, and how the utilization management criteria are generated; and

4. Specimen forms of the letters regarding appeal rights and decisions on appeals that will be sent to covered persons and providers.

(i) An ODS that processes complaints of covered persons shall submit the following information:

1. The ODS' policies and procedures for handling complaints from covered persons, demonstrating that the ODS' policies and procedures are consistent with N.J.A.C. 11:24B-3.1 2;

2. A detailed explanation, including a flow chart, of how the ODS' complaint handling functions are linked and coordinated with each of the contracted carriers' continuous quality improvement and complaint systems (or the carriers' contractors, as appropriate), as required by N.J.A.C. 11:24B-3.1 0;

3. An explanation of how the ODS segregates complaints among carriers as well as other clients on whose behalf complaints are being handled, if the ODS performs complaint handling on behalf of multiple clients; and

4. Specimen forms of the letters regarding a complaint and complaint resolution to be sent to a covered person and provider, if the provider has filed the complaint on behalf of a covered person.

(j) An ODS that handles complaints of providers shall submit the following information:

1. The ODS' policies and procedures for handling complaints from providers, demonstrating that the ODS' policies and procedures are consistent with N.J.A.C. 11:24B-3.1 1;

4. Specimen forms of the letters regarding a complaint and complaint resolution to be sent to a provider.

(k) An ODS that engages in performance of continuous quality improvement shall submit the following information:

1. The policies and procedures of the ODS with respect to the continuous quality improvement program, demonstrating that the continuous quality improvement program meets the requirements of N.J.A.C. 11:24B-3.1 0;

2. A detailed explanation, including a flow chart, of how the continuous quality improvement program managed by the ODS on behalf of the carrier(s) is linked to and coordinates with the carriers' complaint systems and other continuous quality improvement components that the carrier may have in addition to that established by the ODS; and

3. The name of the New Jersey-licensed medical director with oversight of the continuous quality improvement program, a statement as to whether he or she is employed by the ODS or the carrier, and an explanation of the involvement of the medical director in the operations of the continuous quality improvement program.

N.J. Admin. Code § 11:24B-2.4

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
Rewrote (c)3 and the introductory paragraphs of (e) through (k).