N.J. Admin. Code § 11:6-2.14

Current through Register Vol. 57, No. 1, January 6, 2025

Section 11:6-2.14 - Peer and utilization review programs

(a) The WCMCO shall have a program providing adequate methods of peer review and utilization review to prevent inappropriate or excessive treatment which shall include, but not be limited to, the following:

1. A pre-admission review program, which requires physicians to obtain prior approval from the WCMCO for all non-emergency admissions to the hospital and for all non-emergency surgeries prior to surgery being performed;

2. Individual case management programs, which search for ways to provide appropriate care at lower cost for cases which are likely to prove very costly, such as physical rehabilitation or psychiatric care;

3. Physician profile analysis, which shall include each physician's total charges, number and costs of related services provided, time loss of claimant, and total number of visits in relation to care provided by other physicians to persons with the same diagnosis;

4. Concurrent review programs, which periodically review the worker's care after treatment has begun, to determine if continued care is medically necessary;

5. Retrospective review programs, which examine the worker's care after treatment has ended, to determine if the treatment rendered was excessive or inappropriate; and

6. Second surgical opinion programs which describe the worker's ability to obtain the opinion of a second physician when non-emergency surgery is recommended.

(b) The WCMCO shall have a utilization management program to monitor the appropriate utilization of health care services. The program shall be under the direction of the medical director or his or her physician designee. The utilization management program shall be based on a written plan that is reviewed at least annually by the WCMCO. The plan shall identify at least:

1. The scope of utilization management activities, including precertification, case management, concurrent review, retrospective review and second surgical opinion, if applicable;

2. Procedures to evaluate clinical necessity, access, appropriateness and efficiency of services;

3. Clinical review criteria and protocols used in decision-making;

4. Mechanisms to ensure consistent application of review criteria;

5. Qualifications of staff who render determinations to deny or limit an admission, service, procedure or extension of care;

6. A description of when and how utilization management staff may be reached;

7. The time frames for the various stages of the review process so as not to interfere with the provision of care;

8. The policy governing the second surgical opinion program, which describes the worker's ability to obtain the opinion of a second physician when non-emergency surgery is recommended;

9. Mechanisms for coordinating and communicating with the quality improvement program; and

10. Mechanisms to detect underutilization and overutilization of services.

(c) Utilization management criteria shall be based on current and generally accepted medical standards, developed with involvement from appropriate providers with current knowledge relevant to the criteria.

N.J. Admin. Code § 11:6-2.14

New Rule, R.2004 d.41, effective 1/20/2004.
See: 35 New Jersey Register 3541(a), 36 New Jersey Register 520(a).