Current through Register Vol. 56, No. 6, March 18,
2024
(a) Carriers shall
complete and submit to the Department the HCQA Registration Form, available
from the Department upon request, describing, if required, the carrier's
internal appeal process, by which covered persons, or a provider on behalf of a
covered person (with the covered person's consent), may appeal a carrier's UM
decision, and the carrier's notice to covered persons of the right to appeal a
carrier's final UM decision to the Independent Health Care Appeals Program. A
carrier's Selective Contracting Arrangement (SCA) application filed with the
Department pursuant to N.J.A.C. 11:4-37 shall meet the requirements of this
section.
1. Carriers shall file the HCQA
Registration Form at least 30 days prior to the date that the carrier will
begin to offer any health benefits plan issued under a policy or contract form
for which an HCQA Registration Form has not previously been filed.
2. Completion of the HCQA Registration Form
with respect to the description of the carrier's internal appeals mechanism and
its notice of a covered person's right to appeal through the Independent Health
Care Appeals Program shall be consistent with the requirements of
11:24A-3.5.
3. Carriers shall file a copy of the HCQA
Registration Form with the Department at the following address:
Department of Banking and Insurance
Consumer Protection Services
Office of Managed Care
PO Box 329
Trenton, NJ 08625-0329
(888) 393-1062
(b) Carriers shall submit a revised HCQA
Registration Form pursuant to (a)3 above no later than 10 business days
following the date of any substantive change to the information contained in
the prior HCQA Registration Form submission.
1. In lieu of resubmission of the entire HCQA
Registration Form, carriers may submit an HCQA Registration Form indicating the
revisions only, and specifying for unchanged sections "No change from the
submission of (specify date)."
(c) The HCQA Registration Form shall include
a request for the following information:
1.
General information about the carrier, including the carrier's name and NAIC
number, address, the name of the person completing the form and the means by
which that person may be contacted, an explanation of what type of carrier the
carrier is, a statement as to whether the carrier has health benefits plans
inforce in New Jersey, or the date the carrier intends to begin offering health
benefits plans in New Jersey, and the name of the person responsible for the
carrier's operations in New Jersey, with specification of how that person may
be contacted;
2. A statement as to
whether the carrier does or will administer any of its health benefits plans
using utilization management features, and whether any of the carrier's health
benefits plans are managed care plans;
3. If a carrier's health benefits plans
incorporate utilization management features or are managed care plans, a
statement identifying the carrier's medical director for those health benefits
plans, and any other persons responsible for the carrier's utilization
management program, along with a description of the appeal process that the
carrier uses for its health benefits plans;
4. If a carrier's health benefits plans
incorporate utilization management features or are managed care plans, a
general description of the nature of each product, including its form number
and market name; and
5. A
certification that the answers contained in the form are accurate.
