N.J. Admin. Code § 11:24B-3.7

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

Section 11:24B-3.7 - ODS: utilization management guidelines development

(a) In order for an ODS to be certified to perform development of UM guidelines, the ODS shall comply with the following:

1. The ODS shall designate a medical director to be responsible for its UM guidelines program who is licensed to practice medicine in New Jersey; or acknowledge that its utilization management program is under the ultimate oversight of the medical director of the carrier with respect to the carrier's health benefits plans, and the carrier's medical director is licensed to practice medicine in New Jersey; and

2. The UM guidelines developed by an ODS shall:

i. Be a written plan that is reviewed at least annually, and updated as appropriate, and which specifies at least the following:

(1) The procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;

(2) The mechanisms to detect underutilization and over utilization of services; and

(3) The clinical review criteria and protocols used in decision-making; and

ii. Be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be based upon generally accepted medical standards.

N.J. Admin. Code § 11:24B-3.7

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 (a), deleted "the requirements of N.J.A.C. 11:24B-3.4(b), and" following "with"; in (a)1, inserted "and" at the end; in (a)2ii, substituted a period for "; and" at the end; and deleted (a)3.