Section 17B:30-55.8 - [Effective 1/1/2025] Prior authorization, denial, limitation imposed by payer, physician, scope of actions
Any denial of a request for prior authorization or limitation imposed by a payer on a requested service on the basis of utilization management determination shall be made by a physician who shall:
a. make the adverse determination under the clinical direction of a medical director of the payer who shall:(1) be licensed in this State; and(2) strictly follow a medical policy that has been developed and made available in accordance with P.L. 2023, c. 296 (C.17B:30-55.1 et al.) and the "New Jersey Health Care Quality Act," P.L. 1997, c. 192 (C.26:2S-1 et seq.);b. not be compensated by a payer based on the approval or denial rate of the reviewing physician; andc. not be provided preferential treatment by a payer in the requests for prior authorization of the reviewing physician if that physician is also a network provider for the payer.