N.J. Admin. Code § 11:3-28.10
Current through Register Vol. 56, No. 21, November 4, 2024
Section 11:3-28.10 - Insurers' obligations to investigate and audit bills for medical benefits(a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000 and an on-site audit where such claims are equal to or in excess of $50,000. 1. Failure of an insurer to complete an audit in accordance with these rules shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.2. Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter.3. An insurer shall conduct any such audit to determine whether the level of care, need and charges are appropriate.4. An insurer may pay 80 percent of the provider's bill prior to completion of the initial on-site audit. The remaining amount due, if any, shall be paid following completion of the insurer's audit.5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of the audit; and6. Whenever a change in services occurs such as, but not limited to, the level of care, the daily room rate or additional charges, an insurer shall conduct an on-site audit and shall provide the audit and auditor's statement to the Fund with the next reimbursement request.7. All other audits shall be conducted prior to payment to the health care facility and may be performed on a pre-screen basis as set forth in (e) below.(b) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by providers other than health care facilities where such claims are equal to or in excess of $10,000. 1. Failure of an insurer to complete an audit in accordance with this subchapter shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.(c) The thresholds in (a) and (b) above are cumulative for each confinement associated with damages resulting from bodily injuries arising out of the ownership, maintenance or use of a motor vehicle in this State and shall incorporate all claims submitted per confinement by the provider.(d) To be eligible for reimbursement by the Fund, insurers shall audit, prior to payment, bills submitted for continuous treatment from any provider which exceed or may exceed the applicable threshold.(e) Audits of all providers conducted pursuant to this subchapter, including the audit of DRG bills and successor pricing, shall be performed by: 1. Licensed nursing personnel with two years experience or training in required auditing and hospital practices; or2. An outside auditing firm retained by the insurer for such purposes.(f) Audits performed shall include, but not be limited to, confirmation of compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 including those situations where the insurer does not provide the primary coverage to the claimant.(g) An insurer is not required to conduct a separate, independent audit, if it has obtained a true copy of an audit conducted by the primary insurer or health insurer.(h) Insurers shall append copies of audits conducted, including those conducted by the primary insurer or health insurer, and the auditor's statements with the reimbursement request filed with the Fund in accordance with 11:3-28.7.N.J. Admin. Code § 11:3-28.10
New Rule, R.1993 d.583, effective 11/15/1993.
See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a).
Amended by R.1998 d.591, effective 12/21/1998 (operative March 22, 1999).
See: 30 N.J.R. 3202(a), 30 N.J.R. 4390(b).
In (b), inserted "other than health care facilities" following "providers" in the introductory paragraph; in (c), deleted "health care facility or by each individual" preceding "provider"; and in (d) and (e), deleted references to health care facilities.
Amended by R.2006 d.243, effective 7/3/2006.
See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c).
In (a), added "and an on-site audit where such claims are equal to or in excess of $ 50,000"; in (a)3, substituted "any such audit" for "an initial on-site audit for changes by health care facilities".