New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 22 - HEALTH BENEFIT PLANS
Subchapter 4 - ORGANIZED DELIVERY SYSTEMS
Section 11:22-4.5 - Application review procedures

Universal Citation: NJ Admin Code 11:22-4.5

Current through Register Vol. 56, No. 24, December 18, 2024

(a) The Commissioner shall review an application for licensure and notify the applicant of any deficiencies contained therein within 60 days of receipt. An applicant shall address any deficiencies in its application within 60 days of notice thereof.

(b) Upon receipt and review of a complete application that contains all of the information set forth in N.J.A.C. 11:22-4.4, the Commissioner shall issue a license to an organized delivery system if he or she finds that the system meets the following standards:

1. The persons responsible for conducting the applicant's affairs are competent, trustworthy and possess good reputations, and have had appropriate experience, training and education;

2. The persons who are to perform the health care services are properly qualified;

3. The organized delivery system has demonstrated the ability to assure that health care services will be provided in a manner which will assure the availability and accessibility of the services;

4. The standard forms of provider agreements to be used by the organized delivery system are acceptable, and comply with all requirements set forth at N.J.A.C. 11:24C-4 and 11:24B-2;

5. The applicant is financially sound and may reasonably be expected to meet its obligations to enrollees, contract holders and carriers. In making this determination, the Commissioner shall consider:
i. The financial soundness of the applicant's compensation arrangements for the provision of health care services;

ii. The adequacy of working capital, other sources of funding (including an acceptable capital and surplus guarantee from a parent or affiliate) and provisions for contingencies;

iii. Whether any deposit of cash or securities, or any other evidence of financial protection submitted, meets the requirements set forth in N.J.S.A. 17:48H-1 et seq. and this subchapter; and

iv. The standards set forth in N.J.A.C. 11:2-27;

6. Any deficiencies identified by the Commissioner have been corrected;

7. The applicant certifies that it is familiar and will comply with all requirements of law pertaining to licensed organized delivery systems set forth in N.J.S.A. 17:48H-1 et seq. and this subchapter; and

8. Any other factors determined by the Commissioner to be relevant regarding a particular applicant have been addressed to the satisfaction of the Commissioner.

(c) The Department may defer the review of an application accepted after November 1 until the most recent financial information becomes available if, based on the information provided in the application, the Department determines that it is necessary to review more recent financial information to evaluate properly the applicant's financial position.

(d) An applicant shall be notified of the decision on an application within 90 days of receipt of a complete application that contains all of the information set forth in N.J.A.C. 11:22-4.4, or within 90 days of the beginning of the review period set forth in (c) above.

(e) The Commissioner may deny an application for a license if the applicant fails to meet any of the standards provided in this subchapter or on any other reasonable grounds. If the license is denied, the Commissioner shall notify the applicant and shall set forth the reasons for the denial in writing. An existing organized delivery system seeking licensure whose application is denied may request a hearing by notice to the Commissioner within 30 days of receiving the notice of denial. The hearing shall be conducted in accordance with the Administrative Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq., and Uniform Administrative Procedure Rules, N.J.A.C. 1:1. Upon such denial, the applicant shall submit to the Commissioner a plan for bringing the organized delivery system into compliance or providing for the closing of its business.

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