N.J. Admin. Code § 11:24B-4.6

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

Section 11:24B-4.6 - Utilization management guidelines development

(a) The contract shall detail the services that the ODS is performing on behalf of the carrier, specifying the general areas of health care services for which the UM guidelines are being developed or maintained.

(b) The contract shall specify that the ODS is obligated to assure and provide demonstration of involvement of practicing physicians and other licensed providers in the development and review of UM guidelines.

1. If the area of health care services for which UM guidelines are being developed and maintained is limited, the ODS and carrier may agree that involvement of practicing physicians and other licensed health care providers may be limited to those providers engaged in the provision of the types of health care services at issue; however, if such a limitation applies, this shall be stated in the contract with specificity as to composition of the committee(s) that the ODS will utilize to develop and review the guidelines.

(c) If one or more of the health benefits plans of the carrier with which the ODS will contract is a managed care plan, the management agreement shall specify that the ODS is obligated to establish a mechanism for providers in the carrier's network, or in the network(s) with which the carrier contracts, to review and provide comment on the UM guidelines established by the ODS and be able to demonstrate compliance with this requirement.

1. The management agreement shall specify whose responsibility it is to disseminate information to participating providers regarding the ability of participating providers to review and comment on the UM guidelines.

N.J. Admin. Code § 11:24B-4.6