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-4.5 - Designation of a medical director

Universal Citation: NJ Admin Code 11:24A-4.5

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

(a) The carrier shall designate a physician licensed to practice medicine in New Jersey to serve as the medical director for the carrier with respect to its contracts or policies delivered in this State to which a utilization management program applies.

(b) The medical director shall be responsible for the same functions set forth at 11:24A-3.3(b).

1. Defining responsibilities and inter-relationships of professional services for health benefits plans offered with a gatekeeper system;

2. Coordinating, supervising and overseeing the functioning of medical services for health benefits plans offered with a gatekeeper system;

3. Evaluating the medical aspects of provider contracts;

4. Establishing and overseeing a committee to perform the following functions:

i. Establishment of a mechanism for ensuring review of provider credentials;

ii. Delineation of qualifications of participating providers;

iii. Review of credentials of physicians and other providers who do not meet the carrier's standard credentialing requirements; and

iv. Establishment of a mechanism for:

(1) Verifying provider credentials, recertifications, and performance reviews; and

(2) Obtaining information regarding any disciplinary action against a provider available from the New Jersey Board of Medical Examiners or any other state licensing board applicable to the provider, or from the Federal Clearinghouse established pursuant to the Health Care Quality Improvement Act, Pub. L. 99-660 ( 42 U.S.C. §§ 11101 et seq.);

5. Implementing a procedure that provides participating providers an opportunity to review and comment on all medical, surgical and dental protocols of the carrier applicable to the class of provider used for the purpose of utilization management, and protocols for practice guidelines if the carrier imposes practice guidelines upon its participating providers;

6. Implementing a system to assure that covered persons have a choice of providers available to render services covered in-network under the carrier's contracts and policies; and

7. With respect to carrier contracts and policies in which the covered person may be required to select a primary care provider (whether or not referral through the primary care provider also is required in order to access specialty care in-network, or to receive benefits out-of-network), implementing a system through which the covered person may readily change his or her primary care provider at a time other than an open enrollment period, and covered persons are made aware of this right.

i. A carrier shall make a change in PCP effective no later than 14 days following the date that a covered person elects to change his or her provider selection, when such change is discretionary, and shall make the change effective immediately when the change is the result termination of a covered person's PCP from the network.

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