New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 22 - HEALTH BENEFIT PLANS
Subchapter 1 - PROMPT PAYMENT OF CLAIMS
Section 11:22-1.11 - Internal appeals-dental plan organizations and dental service corporations
Universal Citation: NJ Admin Code 11:22-1.11
Current through Register Vol. 56, No. 24, December 18, 2024
(a) Every dental plan organization and dental service corporation shall establish an internal appeals mechanism to resolve disputes between dental carriers or their agents and participating health care providers relating to payment of claims for services or supplies covered by a dental plan. The internal appeal mechanism shall be described in the participating provider contract.
1. The internal review shall be conducted by
employees of the dental carrier who shall be personnel other than those
responsible for claims payment on a day-to-day basis and shall be provided at
no cost to the provider.
2. The
internal review shall be conducted and its results communicated in a written
decision to the provider within 30 days of receipt of the appeal. The written
decision shall include:
i. The names, titles,
and qualifying credentials of the persons participating in the internal
review;
ii. A statement of the
participating provider's grievance;
iii. The decision of the reviewers, along
with a detailed explanation of the contractual and/or medical basis for such
decision;
iv. A description of the
evidence or documentation which supports the decision; and
v. If the decision is adverse, a description
of the method to obtain an external review of the decision.
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