New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 8 - UTILIZATION MANAGEMENT
Section 11:24-8.1 - Utilization management program

Universal Citation: NJ Admin Code 11:24-8.1

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

(a) The HMO shall establish and implement a comprehensive utilization management program to monitor access to and appropriate utilization of health care and services. The program shall be under the direction of the medical director or his or her designee, who shall be a physician, and shall be based on a written plan that is reviewed at least annually by the HMO, and is available for review by the Department upon request. The plan shall identify at least:

1. Scope of utilization management activities;

2. Procedures to evaluate clinical necessity, access, appropriateness, and efficiency of services;

3. Mechanisms to detect underutilization and overutilization;

4. Clinical review criteria and protocols used in decision-making;

5. Mechanisms to ensure consistent application of review criteria and uniform decisions;

6. Development of outcome and process measures for evaluating the utilization management program;

7. System for providers and members to appeal utilization management determinations in accordance with the procedures set forth at N.J.A.C. 11:24-8.4 through 8.7; and

8. A mechanism to evaluate member satisfaction with the complaint and appeals systems set forth at N.J.A.C. 11:24-3.6 and at 11:24-8.4 through 8.7. Such evaluation shall be coordinated with the performance monitoring activities conducted pursuant to the continuous quality improvement program set forth in N.J.A.C. 11:24-7.

(b) Utilization management determinations shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers within the network and based upon generally accepted medical standards. These criteria and protocols shall be periodically reviewed and updated, and shall, with the exception of internal or proprietary quantitative thresholds for utilization management, be readily available, upon request, to members and participating providers in the relevant practice areas.

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