New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 22 - HEALTH BENEFIT PLANS
Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS
Section 11:22-3.6 - Use of clearinghouses in electronic transactions

Universal Citation: NJ Admin Code 11:22-3.6

Current through Register Vol. 56, No. 6, March 18, 2024

(a) When computing the number of days for purposes of acknowledging an electronic claim and/or any other health care transactions required by this subchapter, the following shall apply:

1. When the provider chooses to use a clearinghouse for the transmission of claims to a payer, notice delivered by the payer to the clearinghouse shall constitute notice to the provider.

2. When a payer uses a clearinghouse for the receipt of any electronic transactions required by this subchapter, notice sent by the payer through the clearinghouse shall not constitute notice to a provider until it is delivered to the provider by the clearinghouse, or is available for pickup from the provider's mailbox at the clearinghouse.

3. When a payer and provider use the same clearinghouse for the transmission and receipt of health care transactions, notice that is sent by one party to the clearinghouse shall also constitute notice to the other party.

(b) In those instances where a payer elects to use the services of a clearinghouse (including a clearinghouse that is an affiliate of a payer) for the receipt, transmission, processing, storage and/or other handling of those electronic transactions required by this subchapter, a payer shall only use a clearinghouse that has been accredited by a national standards development organization that is properly authenticated and registered with the United States Attorney General and the Federal Trade Commission pursuant to the provisions of the National Cooperation Research and Production Act of 1993, 15 USC §§ 4301 et seq.

(c) A national standards development organization that desires to accredit clearinghouses in the manner provided in this section may submit proof of its qualifications to do so as set forth in (b) above and a copy of its accreditation criteria or standards, which shall comply with the requirements set forth in (d) below.

(d) The accreditation of a clearinghouse by a national standards development organization shall measure the competency, assets, practices and procedures of the clearinghouse as to the following criteria:

1. Technical capacity and electronic facilities for the receipt, transmission and handling of electronic transactions;

2. Ability to process HIPAA complaint transactions;

3. Backup and disaster recovery plans and capacity;

4. Privacy practices, procedures and employee training programs consistent with HIPAA and the Health Information Electronic Data Interchange Technology Act, 17B:30-23 et seq. (HINT);

5. Security practices, procedures and employee training programs consistent with HIPAA and HINT; and

6. Compliance with the proper procedure for the existence and review of the business associate and trading partner agreements as defined in HIPAA.

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