New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 4 - MEDICAL DIRECTOR
Section 11:24-4.2 - Medical director' responsibility
Universal Citation: NJ Admin Code 11:24-4.2
Current through Register Vol. 56, No. 24, December 18, 2024
(a) The medical director shall be responsible for the direction, provision, and quality of medical services provided to members, including, but not limited to:
1. Defining responsibilities and
inter-relationships of professional services;
2. Coordinating, supervising and overseeing
the functioning of professional services;
3. Evaluating the medical aspects of provider
contracts;
4. Overseeing the
continuing in-service education of professional staff;
5. Providing clinical direction and
leadership to the continuous quality improvement and utilization management
programs;
6. Establishing policies
and procedures covering all health care services provided to members;
7. Establishing a committee that has the
following responsibilities:
i. Establishing
mechanisms for ensuring review of provider credentials;
ii. Delineating qualifications of
participating providers;
iii.
Reviewing credentials of physicians and other providers who do not meet the
HMO's established credentialing standards; and
iv. Establishing a system for verification of
provider's credentials, recertification, performance reviews and obtaining
information about any disciplinary action against the provider available from
the New Jersey Board of Medical Examiners or any other state licensing board
applicable to the provider, or the Federal Clearinghouse established pursuant
to the Health Care Quality Improvement Act, P.L. 99-660 (42 U.S.C. §
1101 et seq.);
8. Implementing a procedure that provides
participating providers an opportunity to review and comment on all applicable
medical, surgical and dental protocols of the HMO applicable to the area of
practice of the provider; and
9.
Implementing a system through which a member may readily change his or her PCP
outside of an annual open enrollment period, and is made aware of this right,
which system shall be applicable to all of the HMO's contracts including its
POS contracts, regardless of whether referral through the PCP is required in
order to access specialty care in-network or to receive benefits
out-of-network.
i. An HMO shall make the
selection of a new PCP effective no later than 14 days following the date of
the selection when such change is discretionary, and shall make the selection
of a new provider immediately effective when change of the PCP is necessitated
by termination of the PCP from the network.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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