New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS
Subchapter 4 - PROVISIONS APPLICABLE TO CARRIERS OFFERING ONE OR MORE HEALTH BENEFITS PLANS THAT ARE MANAGED CARE PLANS
Section 11:24A-4.13 - Continuous quality improvement

Universal Citation: NJ Admin Code 11:24A-4.13

Current through Register Vol. 56, No. 6, March 18, 2024

(a) In addition to complying with 11:24A-3.8, carriers shall comply with the requirements of 11:24-7.1 not otherwise included in 11:24A-3.8.

(b) A carrier shall have performed and shall submit to the Department, by May 1, 2002 or entrance of the carrier into the managed care plan market, and every 36 months thereafter, documentation of its most recent external quality audit performed by an external quality audit review organization approved by the Department.

1. The carrier shall submit the documentation to the Department within 60 days of its receipt in final form by the external quality review organization.

2. The carrier shall make such documentation available to the Department upon request.

(c) The documentation shall describe in detail the carrier's conformance to the standards of the external quality review organization, other standard-setting bodies for carriers of the category to which the carrier belongs, and/or the rules of this State applicable to the carrier and its managed care plans.

1. The documentation also shall describe any recommended corrective actions for the carrier, and whether or not the corrective actions have been undertaken by the carrier and approved, in whole or in part, by the external quality review organization.

(d) The Department shall grant a deferral to a carrier, upon its request, of the requirements of (c) above for up to a 12-month period if it is the initial three years of start-up of the carrier's operations in New Jersey, and it demonstrates a financial or operational hardship.

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