N.J. Admin. Code § 11:24B-4.8

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

Section 11:24B-4.8 - Utilization management appeal program

(a) The contract shall specify how the ODS will comply with 11:24A-3.5, 11:24-8.4 through 8.6 or 11:24A-4.1 2, as applicable.

(b) If the ODS and the carrier agree that the ODS will review UM appeals submitted by a provider without requiring the consent of the covered person, the contract shall specify this, and contain provisions requiring the ODS to notify the provider and provide information in accordance with 11:24B-3.8(b).

(c) The contract shall specify the address of the entity(ies) to which covered persons and providers acting on behalf of covered persons shall be referred for purposes of pursuing a Stage 1 and Stage 2 appeal, as set forth in N.J.A.C. 11:24-8 and 11:24A-3.5, including the availability of telephonic access.

1. Notwithstanding the address specified, the contract shall specify the obligation of the ODS, when corresponding with a covered person, to always identify that the ODS is acting on behalf of the carrier.

(d) The contract shall specify the information that the ODS shall maintain for the carrier, when such information shall be reported or transferred to the carrier, and the manner in which the ODS' utilization management appeal mechanism coordinates with the carrier's continuous quality improvement program.

1. The data collected by the ODS shall be at least that information that the carrier is required to report periodically to DOBI regarding appeals and the utilization management program.

N.J. Admin. Code § 11:24B-4.8

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
In (a), deleted "if performance only will be with respect to health benefits plans that are not managed care plans, or N.J.A.C." following "11:24A-3.5," and substituted "as applicable" for "if performance is with respect to one or more health benefits plans that are managed care plans".