Current through Register Vol. 56, No. 24, December 18, 2024
(a) A carrier or
its agent shall either deny or dispute a claim, in full or in part, that has
not been processed according to 11:22-1.5. If only a portion
of a claim is disputed or denied, the carrier or its agent shall remit payment
for the uncontested portion in accordance with 11:22-1.5. A
carrier's or its agent's characterization of a claim as pending shall not
release the carrier of its obligation to either deny or dispute a claim in
accordance with this section. The carrier or its agent shall, within 30 or 40
calendar days of receipt of the claim, whichever is applicable, notify the
covered person, when he or she will have increased responsibility for payment,
and the provider of the basis for its decision to deny or dispute, including:
1. The identification and explanation of all
reasons why the claim was denied or disputed;
i. A carrier or its agent shall not deny or
dispute a claim for reasons other than those identified in the first review
after the claim is entered, unless information or documentation relevant to the
claim is received after the first review and such documentation leads to
additional reasons to deny or dispute which were not present at the time of
that review.
2. If the
claim is incomplete, the notice shall include a statement specifically
identifying the substantiating documentation or other information that is
required for adjudication of the claim.
3. If the diagnosis coding, procedure coding,
or any other required information required to be submitted with the claim is
incorrect, the notice shall include a statement specifically identifying the
information that must be corrected for adjudication of the claim;
4. If the carrier or its agent disputes the
amount of the claim in whole or in part, the notice shall include a statement
of the basis for that dispute, including any change of coding performed by the
carrier and the reasons for such change of coding;
5. If all or a portion of an electronically
submitted claim cannot be adjudicated because the diagnosis coding, procedure
coding, or any other data required to be submitted with the claim was missing,
the carrier or its agent shall electronically notify the health care provider
or its agent, within seven days of its determination that the claim is missing
required information, and request any information required to complete
adjudication of the claim. If the missing information is subsequently
submitted, the carrier or its agent shall process the claim in accordance with
11:22-1.5 and this section.
6. If the health carrier or its agent finds
there is strong evidence of fraud by the provider and has initiated an
investigation into the suspected fraud, the notice shall state that the health
carrier or its agent finds that there is strong evidence of fraud and, if
applicable, that it has initiated an investigation into the suspected fraud in
accordance with its fraud prevention plan established pursuant to
N.J.S.A. 17:33A-15, and referred the claim,
together with supporting documentation, to the Office of the Insurance Fraud
Prosecutor in the Department of Law and Public Safety and the Bureau of Fraud
Deterrence in the Department pursuant to N.J.S.A. 17:33A-9.
7. The notice shall include the toll-free
telephone number through which the carrier or its agent can be contacted by the
provider or covered person to discuss the claim.
(b) If a carrier or its agent denies or
disputes a claim in whole or in part and fails to provide the notice required
by (a) above, within the timeframes and in the manner required of carriers that
are subject to
P.L.
2005, c. 352 the claim
shall be deemed to be overdue.
(c)
If a carrier or its agent subject to the provisions of N.J.S.A. 17:33A-1 et seq., has reason to
believe that the claim has been submitted fraudulently, it shall investigate
the claim in accordance with its fraud prevention plan established pursuant to
N.J.S.A. 17:33A-15 and, if applicable, refer
the claim to the Office of the Insurance Fraud Prosecutor in the Department of
Law and Public Safety and the Bureau of Fraud Deterrence in the
Department.
(d) Unless otherwise
provided by law, every carrier or its agent shall pay the amount finally agreed
upon in settlement of all or part of any claim not later than 10 working days
from either the receipt of such agreement by the carrier or the date the
performance by the covered person or the provider of any conditions to payment
set forth in the agreement, whichever is later.
