Current through Register Vol. 56, No. 18, September 16, 2024
(a) A carrier's
UM program shall be under the direction of the medical director, or his or her
designee (who shall be a physician licensed to practice medicine in the State
of New Jersey), and shall be based on a written plan, reviewed annually by the
carrier, and available for review by the Department upon request, specifying at
least:
1. The scope of the carrier's UM
activities;
2. The procedures to
evaluate clinical necessity, access, appropriateness, and efficiency of
services;
3. The mechanisms to
detect underutilization and over utilization of services;
4. The clinical review criteria and protocols
used in decision-making;
5. The
mechanisms to ensure consistent application of review criteria and uniform
decisions;
6. The development of
measures for evaluating the carrier's UM program, including outcome and process
measures when the carrier utilizes a gatekeeper system or practice guidelines
for its managed care product(s);
7.
A system for covered persons, and providers on behalf of covered persons (with
the covered person's consent) to appeal UM determinations in accordance with
the procedures set forth at
11:24A-3.5; and
8. A mechanism to evaluate the satisfaction
of covered persons with the appeals system, which mechanism shall coordinate
with the carrier's CQI program required pursuant to
11:24A-3.8.
(b) Carriers shall ensure that UM
determinations are based on written clinical criteria and protocols developed
with involvement from practicing physicians and other licensed health care
providers and based upon generally accepted medical standards.
1. The carrier shall periodically review (no
less than annually) and update these criteria as necessary.
2. The carrier shall make the criteria
readily available, upon request, to covered persons and interested providers
except that internal or proprietary quantitative thresholds for UM is not
required to be released to covered persons or providers pursuant to this
subchapter.
i. When the request is related to
specific treatment or services for which benefits are being sought, the
information provided may be limited to all criteria and protocols by which the
carrier performs UM relevant to only that treatment or services.
(c) The carrier shall
provide access to UM services as follows:
1.
For routine utilization-related inquiries, covered persons and providers shall
have access to UM staff on, at a minimum, a five-day, 40 hours a week basis
through a toll-free telephone number.
(d) The carrier shall have written policies
and procedures, available for review by the Department upon request, that
address the responsibilities and qualifications of staff who render
determinations to authorize admissions, services, procedures or extensions of
stay meeting the following:
1. All
determinations to deny or limit an admission, service, procedure or extension
of stay, or benefits therefor, shall be made in accordance with the clinical
and medical necessity criteria developed in accordance with (b) above, and
rendered by a physician under the clinical direction of the medical director
required pursuant to
11:24A-3.3.
i. The physician shall communicate the
determination directly to the provider or, if this is not possible, the
physician shall supply his or her name, telephone number and where he or she
may be reached so that the provider may contact the physician for further
discussion.
ii. The physician
rendering the determination shall be available immediately to the treating
provider in urgent or emergency cases and on a timely basis for all other cases
as required by the medical exigencies of the situation;
2. All determinations shall be made on a
timely basis, as required by the exigencies of the situation; and
3. A carrier shall notify a provider and/or
covered person of a determination concerning an urgent care claim and
determined by the attending provider as soon as possible, taking into account
the medical exigencies, but no later than 72 hours after receipt of the urgent
care claim by the carrier, of a determination concerning a non-urgent
pre-service claim (that is, prior authorization) no later than 15 days after
receipt of the pre-service claim by the carrier, and of a determination
concerning post-service claims no later than 30 days after receipt of the
post-service claim by the carrier.
(e) A carrier shall not reverse a utilization
management decision where the provider relied upon the written or oral
authorization of the carrier (or its agents) prior to providing the service to
the covered person, except in cases where there is material misrepresentation
or fraud.
(f) A carrier shall
provide written notice within two business days of any determination to deny
coverage or authorization of services or payment of benefits therefor otherwise
covered under the contract or policy of the covered person, and shall include
an explanation of the appeal process.
