N.J. Admin. Code § 11:4-23.10

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

Section 11:4-23.10 - Standards for claims payment

(a) Every carrier providing Medicare supplement policies and certificates shall comply with Section 1882(c)(3) of the Social Security Act as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 ( P.L. 100-203) by:

1. Acceptance of notice from a Medicare-Carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits under the Medicare supplement policy or certificate as sufficient claim notice without requiring other or additional claims forms to be submitted, and making a payment determination based on the information contained in the notice from the Medicare-Carrier;

2. Notification of the participating physician or supplier, and the beneficiary, of the payment determination, and making payment directly to the participating physician or supplier;

3. Providing each enrollee, at the time of enrollment, a card listing the policy name, policy number, and a mailing address to which notices from a Medicare-Carrier may be sent;

4. Payment of user fees for claim notices that are transmitted electronically or otherwise; and

5. Providing to the Secretary of Health and Human Services at least annually, a central mailing address to which all claims may be sent by the Medicare-Carrier.

(b) Compliance with the requirements set forth in (a) above shall be certified on the Medicare supplement experience reporting form.

(c) Payment of benefits for Medicare eligible expenses shall be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity, as are applicable to Medicare claims.

N.J. Admin. Code § 11:4-23.10

New Rule, R.1991 d.345, effective 7/1/1991.
See: 23 New Jersey Register 1264(a), 23 New Jersey Register 2014(a).
Prior section 23.7 Loss Ratio Standards recodified to 23.8.
Amended by R.1993 d.26, effective 1/4/1993.
See: 24 New Jersey Register 12(a), 25 New Jersey Register 141(a).
Standards for claims payment recodified from 23.7; requirements for compliance specified at (a)1 through 5.