N.J. Admin. Code § 11:6-2.5

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

Section 11:6-2.5 - Workers' compensation managed care organization approval procedures

(a) The WCMCO shall file an application for approval with the Department at the following address:

New Jersey Department of Banking and Insurance

Office of Consumer Protection Services

Managed Care

Attn: WCMCO

20 West State Street

PO Box 329

Trenton, NJ 08625-0329

(b) The WCMCO application form and filing instructions can be found on the Department's website:

http://www.state.nj.us/dobi/division_insurance/managedcare/mcapps.htm. The WCMCO application shall include the following:

1. Copies of the WCMCO basic organizational documents, which shall include the certificate of incorporation and/or by-laws indicating managed care responsibilities, if applicable;

2. A general diagram illustrating functional responsibilities within the WCMCO which shall also identify all subcontracted entities and the functions they perform;

3. An organizational chart reflecting all affiliated companies;

4. The location of the place of business where the WCMCO administers the plan and maintains its records;

5. Satisfactory evidence of the WCMCO's ability to meet the financial requirements necessary to ensure delivery of service in accordance with the plan;

6. The WCMCO's most recent audited financial report and the last three quarters unaudited financial reports, or its capitalization and projections if a newly organized WCMCO, as well as any other financial information required by 11:6-2.15;

7. A listing of the WCMCO's officers and directors and of the individuals within the WCMCO responsible for managed care, and a biographical affidavit for each or the NAIC biographical affidavit, which is incorporated herein by reference, as amended and supplemented, and is available at http://content.naic.org/industry/ucaa;

8. Verification of the medical director's board certification;

9. The identity of a communication liaison for the Department, employers, workers and the insurer at the WCMCO's location. The responsibilities of the liaison shall include, but not be limited to, responding to questions and providing direction regarding outgoing correspondence, medical bills, case management and medical services;

10. A narrative description of the places and protocol of providing services under the plan, including a description of the initial geographical service area. The geographical service area shall be designated as the counties in which work sites are located; a description of the number and type of disciplines of medical service providers to treat work-related injuries and illnesses, such as orthopedic, chiropractic, dental and ophthalmologic services; and a description of the number of care coordinator physicians in the WCMCO. The WCMCO shall maintain an adequate number of care coordinator physicians to provide the level and quality of medical treatment and services as required under the Workers' Compensation Law, N.J.S.A. 34:15-1 et seq. The requirements of this paragraph shall be met unless the WCMCO adequately demonstrates the unavailability of a particular type of provider in a particular geographic service area;

11. A list of the names, addresses and specialties of the individuals, providers, rehabilitation centers, hospitals and other facilities that will provide services under the managed care plan. This list shall indicate which medical service providers will act as care coordinator physicians within the WCMCO. In addition, the WCMCO shall provide a map of the service area, indicating the location of the providers by type;

12. Copies of specimen contracts and, when available, executed contracts between the WCMCO and insurer;

13. Copies of contracts and/or agreements between the WCMCO and any provider network subcontractors. Copies of executed signature page(s) of such contract, agreement or other document for each subcontractor shall be sent only upon request;

14. Specimen copies of all provider agreements between the WCMCO or its subcontractors and each participating medical service provider. Copies of executed signature page(s) of such provider agreements shall be sent only upon request. All provider agreements or amendments shall comply with the provisions or N.J.A.C. 11:6-2.10;

15. Evidence of or the WCMCO's certification of minimum malpractice insurance in the amount of $ 1,000,000/$ 3,000,000 for each provider. For non-physician providers, self-insurance is acceptable subject to proof of adequate financial resources;

16. A description of the manner in which the WCMCO is compensated for its services, whether contracted directly with the employer or insurance carrier;

17. A description of the procedures for reimbursement to providers for all services provided in accordance with the WCMCO plan;

18. A description of the WCMCO treatment standards and protocols that will govern the medical treatment provided by all medical service providers, including care coordinator physicians. The number of providers should be adequate as necessary to ensure that workers of employers covered by the WCMCO are able to fulfill the requirements of 11:6-2.12;

19. A description of the WCMCO's quality assurance program, which shall comply with and include, but not be limited to, the following minimum requirements:

i. A system for resolution and monitoring of problems and complaints, including, but not limited to, the problems and complaints of workers;

ii. A program which specifies the criteria and process for physician peer review; and

iii. A standardized claimant medical recordkeeping system designed to facilitate entry of information into computerized databases for purposes of quality assurance;

20. A description of the WCMCO's program, under the direction of a case manager and involving cooperative efforts by the workers, the employer, the insurer, and the workers' compensation managed care organization, to promote early return-to-work for injured workers in compliance with the minimum requirements for such programs set forth in 11:6-2.13;

21. A description of the WCMCO's peer review and utilization review programs in compliance with 11:6-2.14;

22. A description of the WCMCO's procedure for internal dispute resolution, in coordination with the insurer, which shall include a method to resolve complaints by injured workers, medical providers and employers;

23. A description of the method whereby the WCMCO will provide insurers with information to inform employers of all medical service providers within the plan and the method whereby workers may be directed to those providers;

24. A detailed description of the WCMCO's experience with the management of health care costs associated with workers' compensation claims and with other health care claims;

25. The estimated savings in overall medical costs expected from the use of the WCMCO and the methodology used in arriving at such estimate;

26. The outline of the operation of the WCMCO to be provided to employers explaining their rights and responsibilities; and

27. Any other materials specifically requested by the Commissioner in connection with a particular application.

(c) The Department shall review these documents and grant approval, within 60 days of the WCMCO's filing a complete application, to those WCMCOs deemed to meet the criteria set forth in this subchapter. The Commissioner may extend the 60-day time frame an additional 30 days for good cause shown and shall provide notice to the WCMCO of such extension. A decision to deny approval shall be accompanied by a written explanation by the Department of the reasons for denial.

N.J. Admin. Code § 11:6-2.5

Amended by 48 N.J.R. 2621(a), effective 12/5/2016

Amended by 55 N.J.R. 2267(b), effective 11/6/2023