New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 3 - GENERAL REQUIREMENTS
Section 11:24-3.9 - Provider application for participation and the review panel

Universal Citation: NJ Admin Code 11:24-3.9

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

(a) No later than August 29, 2000, an HMO shall establish a committee to review applications submitted by licensed providers to become members of the HMO network.

1. The HMO may combine the functions of this committee with another committee, so long as when performing its application review functions, the committee meets the requirements of this section, but the HMO shall not be required to combine the functions of this review committee with the functions of any committee whose function includes credentialing standards.

2. The committee shall be composed of no less than three people.

3. At least one of the committee members reviewing a specific application shall be health care providers with knowledge in the applicant provider's scope of professional practice.

(b) Unless the committee shall notify the applicant within 60 days following receipt of the application that the application is incomplete, specifying in writing the information that is missing, the application shall be deemed complete.

1. The committee shall complete its review of a complete application within no more than 90 days of receipt of the complete application.

2. The committee shall provide notice of its action on a complete application to the provider in writing.

3. If the committee's acceptance of a complete application does not constitute the offer of a contract to the applicant by the HMO, the committee shall set forth in its notice the remaining procedures to be completed prior to the applicant becoming a participating provider, if at all.

(c) The HMO may establish the factors to be considered by the committee in determining whether an application is complete and whether to accept or reject a complete application.

1. The factors considered by the committee shall be in writing, and shall be available for review by applicants upon request.

2. The formulas or methods of weighting of factors as specified by the HMO shall be confidential information.

(d) The HMO may establish its own application forms, but if it does not elect to establish its own form, the HMO shall make available, upon request, a written notice of what information it requires to be submitted to determine an application is complete.

(e) All applications, notices and guidelines required by this section shall be reviewable upon request by the Department.

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