New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 22 - HEALTH BENEFIT PLANS
Subchapter 1 - PROMPT PAYMENT OF CLAIMS
Section 11:22-1.16 - Explanation of benefits

1. Name of the covered person;

2. Name of the provider;

3. Date of service;

4. Clear description of the service;

5. Billed charge;

6. Allowed charge;

7. Non-covered amount;

8. A specific explanation of why a charge is not covered by the health benefits plan, for example, person not covered on date of service, provider not in network, other coverage is primary, the service is not medically necessary, no prior authorization, no referral, experimental or investigational service, or service is excluded by contract. Use of denial reasons with multiple grounds shall only be used if each denial ground applies to the specific claim, including when the reasons are separated by an "and," similar text, symbol, or punctuation;

9. The amount that is the covered person's responsibility due to deductible, coinsurance, and copayment;

10. The accumulation toward the covered person's deductible, or family deductible, if applicable;

11. The accumulation toward the covered person's maximum out-of-pocket, or family maximum out-of-pocket, if applicable;

12. Amount paid by plan, interest should be shown separately if interest is paid;

13. An explanation of the process to appeal the determination on the claim; and

14. A telephone number that the covered person can call to get additional information on the processing of the claim.