N.J. Admin. Code § 11:24C-3.7

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24C-3.7 - Clinical laboratories at State-recognized outpatient regional hemophilia care centers

(a) When a covered person's attending physician determines that a covered person needs to use the services of a clinical laboratory at a State-recognized outpatient regional hemophilia care center because of timing or the need for closely supervised procedures in venipuncture and laboratory techniques, and the carrier does not have an agreement for the provision of services at any clinical laboratory of a State-recognized outpatient regional hemophilia care center, the carrier shall approve the use of such services at the clinical laboratory of a State-recognized outpatient regional hemophilia care center determined appropriate by the attending physician.

1. The center shall provide services or benefits to or on behalf of the covered person as if the covered person had accessed services in-network when the services are accessed in accordance with (a)1 above.

2. A refusal by a carrier or its agent to provide benefits or services as if in-network under the circumstances set forth in (a)1 above shall be considered a utilization management denial, and subject to the utilization management appeal process set forth at N.J.A.C. 11:24-8 or N.J.A.C. 11:24A-4.1 2, as appropriate to the type of carrier.

(b) When a covered person's attending physician determines that a covered person needs to use the services of a clinical laboratory at a State-recognized outpatient regional hemophilia care center because of timing or the need for closely supervised procedures in venipuncture and laboratory techniques, and the carrier has an agreement for the provision of services at a clinical laboratory of one or more State-recognized outpatient regional hemophilia care centers, the carrier may require use of such services at its contracted facility(ies) in order to obtain in-network benefits or provision of services at the in-network level; however, the carrier shall treat a denial to approve use of the clinical laboratory determined appropriate by the attending physician as a utilization management denial, not an administrative denial, and shall treat any appeal of the denial as a utilization management appeal in accordance with the rules at N.J.A.C. 11:24-8 or N.J.A.C. 11:24A-4.1 2, as appropriate to the type of carrier.

1. If the covered person is covered under a health benefits plan with out-of-network benefits, the carrier may provide services or benefits to or on behalf of the covered person as if the covered person had accessed services out-of-network.

2. If the covered person is covered under a health benefits plan without out-of-network benefits, the carrier shall pay for the laboratory services at the same rate it would pay for comparable services at the State-recognized outpatient regional hemophilia care center(s) in the carrier's network.

(c) Nothing in (a) and (b) above shall be construed to otherwise limit a covered person's rights in obtaining services or a carrier's obligations with respect to providing benefits in an emergency.

(d) Treatment by the carrier of a covered person as in-network when accessing the services of a clinical laboratory at a State-recognized outpatient hemophilia care center shall not be contingent upon the status of the attending physician as an in-or out-of-network health care provider with respect to the managed care plan covering the covered person.

(e) Nothing in this subchapter shall be construed to prevent the carrier from reviewing the services provided and making a determination as to whether the services were medically necessary.

N.J. Admin. Code § 11:24C-3.7