N.J. Admin. Code § 11:24B-4.4

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

Section 11:24B-4.4 - Network management

(a) The contract shall detail the functions that the ODS is obligated to perform on behalf of the carrier with respect to network management, including all health care services and supplies the ODS will arrange to have provided to the carrier's covered persons.

(b) The contract shall specify the factors and thresholds that obligate the ODS to expand or limit the number of providers within its network in order to assure that its network meets the requirements of 11:24-6.2 and 6.3, or 11:24-4.1 0, as appropriate to the type(s) of providers in, and the health care services to be offered through, the network and as appropriate to the type of carrier under contract.

(c) The contract shall specify the compensation arrangement between the ODS and the health care providers in the network.

1. The compensation arrangement shall not provide financial incentives to the providers for the withholding of covered health care services that are medically necessary.

i. An ODS shall not be precluded from using capitated payment arrangements between the ODS and a provider.

ii. Notwithstanding (c)1i above, an ODS shall not use capitation as the sole method of reimbursement to providers who provide primarily supplies (for instance, prescription drugs or durable medical equipment) rather than services.

2. The provision shall specify the process by which the ODS will make payment to providers, which shall be consistent with the standards of P.L. 1999, c. 154 (Health Information Technology Act), as amended, as well as P.L. 1999, c. 155, as amended, and rules promulgated pursuant thereto, including N.J.A.C. 11:22-1.

(d) The contract shall specify the utilization management standards that will apply to the ODS' network.

1. If the provision does not specify that the ODS shall assure compliance with the utilization management standards of the carrier, then the provision shall specify that the carrier adopts and takes responsibility for the utilization management standards to be used by the ODS.

(e) The contract shall specify whether the ODS is responsible for any portion of the utilization management review and appeal process, and shall detail how the ODS and the carrier interact with respect to UM and UM appeals.

(f) The contract shall specify the circumstances under which a carrier may request that the ODS remove a health care provider from participation in the network and/or the carrier's product(s), and the standards applicable to such removal, which shall be the equivalent of a termination of the provider from the carrier's network.

1. With respect to providers that are health care professionals, the contract shall specify that the carrier shall provide the ODS with sufficient advance notice of the desire to terminate the provider so that the health care professional receives at least 90 days prior notice of the termination, and the right to request a hearing, except when termination is:

i. Based on a belief of the carrier that the provider has breached the terms of the provider agreement;

ii. Based on a belief of the carrier that the provider has engaged in fraud;

iii. Based on a belief of the carrier that the provider is an imminent danger to one or more covered persons, or the health, safety or welfare of the public, based on the opinion of the carrier's medical director; or

iv. To occur on the renewal date of the provider's contract, or the anniversary date of the provider's contract, if no renewal date is specified.

2. With respect to providers that are health care professionals, the contract shall specify that the carrier shall make available to the provider, whether directly or through the ODS, a written explanation of the reason for the termination upon request, if such written explanation is not otherwise provided to the health care professional automatically.

3. The contract shall specify what criteria the ODS may request from the carrier in order to effect a termination of the provider.

4. The contract may relieve the ODS of complying with 26:2S-8 and rules promulgated pursuant thereto when the provider is terminated at the request of the carrier, so long as it is stated in the contract that providers shall be directed to the carrier in order to exercise their rights pursuant to 26:2S-8.

5. The circumstances under which a carrier may request termination of a provider shall not be based on the provider filing complaints or appeals in his or her own behalf or on behalf of a covered person, or otherwise acting as an advocate of a covered person in seeking appropriate, medically necessary health care services covered by the covered person's health benefits plan.

(g) The contract shall specify the circumstances under which the ODS may terminate a provider from its network, and the standards for notice to the carrier that the ODS shall provide prior to effecting such a termination.

1. With respect to a health care professional, the ODS shall provide the carrier with sufficient notice so that the carrier's covered persons are afforded at least 30 days prior notice of the termination of the provider, except when:

i. The ODS believes that the provider has breached the terms of the provider agreement;

ii. The ODS believes that the provider has engaged in fraud; or

iii. The ODS believes that the provider is an imminent danger to one or more covered persons, or the health, safety or welfare of the public, based on the opinion of the carrier's or the ODS' medical director.

2. The contract may relieve the carrier of any obligation to comply with 26:2S-8, and rules promulgated pursuant thereto, when the provider is terminated upon the prerogative of the ODS, so long as it is stated in the contract that providers shall be directed to the ODS in order to exercise their rights pursuant to 26:2S-8.

3. The circumstances under which an ODS may terminate a provider shall not be based on the provider filing complaints or appeals in his or her own behalf or on behalf of a covered person, or otherwise acting as an advocate of a covered person in seeking appropriate, medically necessary health care services covered by the covered person's health benefits plan.

(h) The contract shall include provisions obligating the ODS to assure that providers in the network comply with the requirements of 26:2S-9.1 and 26:2J-11.1, and rules promulgated pursuant thereto, as appropriate to the type of provider and the carrier.

1. The obligation to assure that providers comply with continuity of care requirements shall apply regardless of whether the provider is terminated at the request of the carrier, at the prerogative of the ODS, or at the option of the provider.

2. The obligation to assure that providers comply with continuity of care requirements shall apply regardless of the reason for the termination, except that the ODS and the carrier may agree that the provider shall not be permitted to continue to provide care to a covered person as if the provider were in-network if the provider has been terminated on the basis of breach, fraud or imminent danger to a covered person, or the health, safety or welfare of the public.

(i) The contract shall prohibit both the ODS and the carrier from in any way discouraging open communication between providers and the carrier's covered members regarding diagnostic tests and treatment options, and shall specify that the ODS shall not penalize a provider based on complaints or appeals made by the provider in his or her own behalf or on behalf of a covered person, or for otherwise acting as an advocate of a covered person in seeking appropriate, medically necessary health care services covered under the covered person's health benefits plan.

(j) The contract shall require the ODS to assure that its network providers will not bill, or otherwise pursue payment from, a carrier's covered persons for the costs of services or supplies rendered in-network that are covered, or for which benefits are payable, under the covered person's health benefits plan, other than for copayments, coinsurance or deductible amounts set forth in the health benefits plan, regardless of whether the provider agrees with the amount paid, or to be paid, by the ODS or carrier, as appropriate, for the services or supplies.

(k) The contract shall require the ODS to assure that its network providers treat a carrier's members without discrimination.

(l) The contract shall specify the obligation of the ODS to assure that its network providers, if primary care providers, make health care services available to a carrier's covered person 24 hours per day, seven days per week.

(m) The contract shall specify the obligations of the ODS with respect to implementation and maintenance of a provider complaint and appeal mechanism, and shall detail the way in which the ODS' complaint and appeal mechanism is coordinated with the carrier's continuous quality improvement program.

(n) The contract shall specify the obligations of the ODS with respect to implementation and maintenance of a provider participation panel.

(o) The contract shall specify the obligations of the ODS with respect to implementation and maintenance of a credentialing program, and shall detail the way in which the ODS' credentialing program is coordinated with the carrier's continuous quality improvement program and complaint system(s).

(p) The contract shall specify the manner in which the ODS' continuous quality improvement program and the carrier's continuous quality improvement program coordinate, the information the ODS and carrier are obligated to provide to one another, and the data that each is to collect, including details regarding the timing of reports and information transfers.

N.J. Admin. Code § 11:24B-4.4

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
In (c)2, inserted ", as amended," preceding "as" and "as amended," following "c. 155,"; and deleted (k)1 and (k)2.