N.J. Admin. Code § 11:24B-4.7

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

Section 11:24B-4.7 - Utilization management program

(a) The contract shall specify the features of the ODS' program that assure its compliance with 11:24-8.2 and 8.3 or 11:24A-3.4(c) through (f) and 4.11(b)2, as appropriate to the carrier with which the ODS is contracted, and the health benefits plans for which UM will be provided.

(b) The contract shall specify the obligation of the ODS to develop measures evaluating UM guidelines and application thereof consistent with 11:24B-3.7(a)2, to make the information obtained from the evaluations available to the carrier, and to coordinate with the carrier's continuous quality improvement program and complaint system(s).