Current
through Register Vol. 56, No. 6, March 18, 2024
(a) All third party administrators subject to
licensure or registration shall obtain licensure or registration prior to
operating in this State.
(b)
Application for licensure or registration shall be made on a form prescribed by
the Commissioner which can be found on the Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm.
The information that shall accompany the application shall include:
1. A copy of the applicant's basic
organizational documents, which shall include articles of incorporation,
articles of association, partnership agreement, management agreement, trust
agreement or other documents governing the operation of the applicant that are
applicable to the applicant's form of business organization;
2. A copy of the executed bylaws, rules and
regulations, or other documents relating to the operation of the applicant's
internal affairs;
3. A biographical
affidavit on the form provided on the Department's website at
www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm
or on the NAIC biographical affidavit form, which is incorporated by reference,
as amended and supplemented, and which can be found on the NAIC website at
http://www.naic.org/documents/industry_ucaa_form11.pdf,
including the name, address, and official position of each person responsible
for conducting the affairs of the applicant, including, but not limited to, if
applicable: the members of the board of directors, executive committee, or
other governing board or committee; the principal officers or partners;
shareholders owning or having the right to acquire 10 percent or more of the
voting securities of the corporation or partnership interest of a partnership,
or equity interest, in the case of another form of business organization; or
any person or entity who has loaned funds to the applicant for the operation of
the business;
4. A statement of any
criminal convictions or civil, enforcement or regulatory action, including
actions relating to professional licenses, taken or pending against any of the
persons who are responsible for the conduct of the affairs of the applicant or
the applicant's affiliates, and the resolution of those actions and
proceedings. If a license, certificate or other authority to operate has been
refused, suspended or revoked by any jurisdiction, the applicant shall provide
a copy of any orders, proceedings and determinations relating
thereto;
5. A copy of the
applicant's most recent financial statements audited by an independent
certified public accountant. If the financial affairs of the applicant's parent
company are audited by an independent certified public accountant, but those of
the applicant are not, then a copy of the most recent audited financial
statement of the applicant's parent company, audited by an independent
certified public accountant, shall be submitted. An audited consolidated
financial statement of the applicant and the parent company shall satisfy this
requirement unless the Commissioner determines that additional or more recent
information is required for the proper administration of the Act; and
6. A copy of the applicant's business plan,
including:
i. A statement generally
describing the applicant, its facilities, personnel, and the services to be
offered by the third party administrator;
ii. Information on activities undertaken or
to be undertaken in New Jersey;
iii. A statement of the applicant's
capability for providing a sufficient number of experienced and qualified
personnel in the areas of claims processing and recordkeeping, and information
on staffing levels, including, but not limited to, training, hiring
requirements, experience of staff;
iv. Evidence of establishment of a separate
account for each benefits payer for payment of claims, with a description of
the controls the applicant has put in place for it;
v. Evidence of a fidelity bond as required by
11:23-3.4;
vi. A description of the applicant's proposed
method of marketing its services in New Jersey;
vii. A statement setting forth the means by
which the applicant will be compensated;
viii. A description of the complaint and
appeals procedures instituted by the applicant;
ix. A description of the quality assurance
procedures established by the applicant;
x. Three-year projections of anticipated
operating results. In addition, the business plan shall include a description
of the assumptions used in the projections that shall include an explanation of
each line item;
xi. A statement of
the sources of working capital and any other sources of funding;
xii. A description of the provision for
contingencies that will enable the applicant to perform the work for which it
has contracted;
xiii. A list of the
benefits payers under contract with the applicant, and a copy of the standard
contract or contracts used by the applicant in the course of business. In the
case of an applicant for registration, the information required to be filed
with the Commissioner shall apply only to services provided to benefits payers
other than an insurer;
xiv. A list
of the subcontractors under contract with the applicant, and a copy of the
standard contract or contracts used by the applicant in the course of business
with subcontractors;
xv. A list of
the reinsurers with whom the applicant does business and copies of the contract
or contracts used by the applicant in the course of business with
reinsurers;
xvi. A list of all
administrative, civil or criminal actions and proceedings to which the
applicant, or any of its affiliates have been subject and the resolution of
those actions and proceedings. If a license, certificate or other authority to
operate has been refused, suspended or revoked by any jurisdiction, the
applicant shall provide a copy of any orders, proceedings and determinations
relating thereto; and
xvii. A power
of attorney, duly executed by the applicant, if not domiciled in this State,
appointing the Commissioner and his or her successors in office as the true and
lawful attorney of the applicant in and for this State upon whom all lawful
process in any legal action or proceeding against the organization on a cause
of action arising in this State may be served.
(c) An applicant shall make available for
inspection by the Commissioner copies of all contracts with benefits payers or
other persons with whom it does business, related to all services provided by
them to benefits payers, including subcontractors and reinsurers.