N.J. Admin. Code § 11:24B-3.8

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

Section 11:24B-3.8 - ODS: utilization management program

(a) In order for an ODS to be certified to operate a utilization management program, the ODS shall comply with the requirements of N.J.A.C. 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f), and:

1. Have a mechanism that ensures consistent application of review criteria and uniform decisions; and

2. Develop measures for evaluating the UM guidelines and application thereof, including outcome and process measures when the carrier utilizes a gatekeeper system or practice guidelines for managed care products.

N.J. Admin. Code § 11:24B-3.8

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
Section was "ODS: Utilization management program". In the introductory paragraph of (a), deleted "on behalf of a carrier" following "program" and updated the N.J.A.C. references; in (a)1, inserted "and" at the end; in (a)2, substituted a period for a semicolon at the end; and deleted (a)3 and (a)4.