N.J. Admin. Code § 11:24B-3.5

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

Section 11:24B-3.5 - ODS: network management

(a) In order to qualify for certification to perform network management, an ODS shall comply with the requirements of 11:24B-3.4(b), and shall perform the following duties, meeting the standards of this section:

1. Recruiting, and maintenance of provider relations systems, in order to assure constant network adequacy with respect to the categories of providers to be included in the ODS' network;

2. Implementation and maintenance of a provider participation panel for the ODS' network;

3. Implementation and maintenance of a credentialing and recredentialing mechanism for the ODS' network;

4. Implementation and maintenance of a provider notice and termination hearing mechanism for the ODS' network;

5. Implementation and maintenance of a complaint mechanism for providers in the ODS' network;

6. Designation of a medical director licensed to practice medicine in New Jersey; and

7. Implementation and maintenance of a continuous quality improvement program for the ODS' network.

(b) With respect to network adequacy, the ODS shall assure that the network meets the standards for determining network adequacy as set forth at 11:24A-4.1 0 or 11:24-6 for those categories of providers in the ODS' network with respect to those services that the providers are required to render.

1. If an ODS is not arranging for the provision of the carrier's entire network, the ODS shall include a statement to this effect in its demonstration, and shall specify the providers for which the ODS is agreeing to be responsible, the geographic location for which the ODS is agreeing to be responsible, and any other limitations that may be applicable to the ODS network.

(c) An ODS shall either designate a medical director for its network who is licensed to practice medicine in New Jersey and who shall be responsible for the following functions, or the ODS shall demonstrate that the medical director of the carrier is licensed to practice medicine in New Jersey, and that the carrier's medical director shall have ultimate oversight of the ODS' network with respect to the carrier's health benefits plans, including, but not necessarily limited to, the following functions:

1. Credentialing in accordance with 11:24-4.2(a)7 or 11:24A-4.5(c)4;

2. Oversight of professional services, staff and education in accordance with 11:24-4.2(a)1 through 4, or 11:24A-4.5(c)1 through 3 and 11:24A-3.3(b)1;

3. Providing direction and leadership to the continuous quality improvement program in accordance with 11:24-4.2(a)5 or 11:24A-3.3(b)2;

4. Establishing policies and procedures covering all health care services to be provided through the ODS' network to covered persons in accordance with 11:24-4.2(a)6 or 11:24A-3.3(b)3; and

5. Implementing or coordinating with the carrier on a procedure that provides participating providers an opportunity to review and comment on all medical, surgical and/or dental protocols applicable to the area of practice of the provider in accordance with 11:24-4.2(a)8 or 11:24A-4.5(c)5.

(d) The ODS shall demonstrate that its provider participation panel is in compliance with either 11:24A-4.7 or 11:24-3.9.

1. The provider participation panel and processes related thereto shall be for the purposes of participation in the ODS' network, and shall not be a substitute for provider participation requirements applicable to carriers.

(e) The ODS shall demonstrate that its provider termination hearing process is in compliance with either 11:24A-4.9 or 11:24-3.6.

1. The provider termination rights and hearing process shall be for the purposes of termination from the ODS' network, and shall not be a substitute for provider termination requirements applicable to carriers.

(f) The ODS shall demonstrate that it shall comply with the standards for provider termination established at either 11:24A-4.8 or 11:24-3.5 with respect to the continuing obligations and rights of health care providers to provide patient care, regardless of whether the provider is terminated from the ODS network by the ODS, or from the carrier's network by the carrier.

(g) The ODS shall demonstrate that its complaint processing system for providers is in compliance with the standards at 11:24A-4.6(b) and (e), or 11:24-3.7(b) and (e).

(h) The ODS shall demonstrate that it has a continuous quality improvement program in place, setting forth the scope of the program, and addressing at least the following:

1. The duties and responsibilities of the ODS' medical director, or the medical director of the carrier with respect to the ODS' CQI program;

2. The contractual arrangements, if any, for delegation of quality improvement activities;

3. Confidentiality policies and procedures;

4. Specification of standards of care, criteria and procedures for the assessment of the quality of services provided by the providers in the ODS' network, and the adequacy and appropriateness of health care resources utilized;

5. A system of ongoing evaluation activities, including individual case reviews as well as pattern analysis;

6. A system of focused evaluation activities, particularly for frequently performed and/or highly specialized procedures, regardless of the type of provider network, or services provided by the network;

7. A system for monitoring the ODS' network providers' response and feedback on the ODS' operations, and the providers' perceptions of the operations of the carriers with which the ODS contracts;

8. The procedures for conducting peer review activities by providers within the same discipline and area of clinical practice;

9. A system for evaluating the effectiveness of the continuous quality improvement program;

10. A system for linking the continuous quality improvement program of the ODS with the continuous quality improvement programs of the carriers with which the ODS contracts, with timely and appropriate transfer of information between the contracted parties;

11. The establishment of a multidisciplinary committee that includes representation from among the providers in the network, administrative staff of the ODS, representation by the carriers with which the ODS is contracted, and nursing staff, if the ODS has nursing staff available to it, which shall be responsible for the implementation and operations of the continuous quality improvement program, including the linkage of the program with the carrier contractors, pursuant to (h)10 above;

i. An ODS may satisfy this requirement by demonstrating participation at multidisciplinary committees established and maintained by the separate contracting carriers, if the ODS is also able to demonstrate that it has in place and utilizes a mechanism for collecting and bringing the points of view of its participating providers to the attention of the multidisciplinary committees on relevant issues; and

12. The establishment of a system for keeping the board of directors or executive committee of the ODS informed of the continuous quality improvement activities, including at least an annual written report delineating quality improvements, performance measures used and their results, and demonstrated improvements in clinical and services quality.

(i) With respect to the continuous quality improvement program of (h) above:

1. If the ODS provides or arranges for the provision of substantially all of the services that a carrier has agreed to cover or make payment of benefits for under the carrier's health benefits plan(s), the ODS' continuous quality improvement program's monitoring of the availability, accessibility, continuity and quality of care shall include at least:

i. A mechanism for monitoring patient appointments and triage procedures, discharge planning services, linkage between all modes and levels of care and appropriateness of specific diagnostic and therapeutic procedures selected by the continuous quality improvement committee;

ii. A mechanism for evaluating all of the network providers, including health care facilities.

(1) A health care facility's internal quality assurance program shall not constitute the only assessment of patient care by the ODS; and

iii. A system to monitor both provider and covered person access to utilization management services, when ODS agreed to perform any utilization management function for the carrier.

2. In determining if an ODS' network provides or arranges for the provision of performance of substantially all of the health care services covered under a carrier's health benefits plan(s), or for which the carrier has agreed to pay benefits under its health benefits plan(s), the Department shall not take into consideration whether the ODS provides or makes arrangement for the provision of pharmaceutical services, behavioral health services, case management, disease management, utilization management, or durable medical equipment, but shall take into consideration whether the ODS provides or arranges for the provision of preventive and primary medical care services, specialty medical and ancillary care services, inpatient services, nursing services, and rehabilitative services.

N.J. Admin. Code § 11:24B-3.5

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
In the introductory paragraph of (b), updated the N.J.A.C. references.