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-4.7 - Provider application for participation

Universal Citation: NJ Admin Code 11:24A-4.7

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

(a) A carrier shall establish a committee to review applications submitted by licensed providers to become members of the carrier's network.

1. The carrier may combine the functions of this committee with another committee, so long as when performing its application review functions, the committee meets the requirements of this section.

2. The carrier shall not be required to combine the functions of this review committee with the functions of any committee whose function includes credentialing standards.

3. The committee shall be composed of no less than three people.

4. At least one of the committee members reviewing a specific application shall be health care providers with knowledge in the applicant provider's scope of professional practice.

(b) The committee shall complete its review of a complete application within no more than 90 days of receipt of the complete application.

1. If the committee determines an application is incomplete, it shall notify the applicant as expeditiously as possible, but in no event later than 60 days following the date of receipt of the application, and inform him or her of the information that is missing.

2. The committee shall provide notice of its action on a complete application to the provider in writing.

3. If the committee's acceptance of a complete application does not constitute the offer of a contract to the applicant by the carrier, the committee shall set forth in its notice to the applicant the remaining procedures to be completed prior to the applicant becoming a participating provider, if at all.

(c) The carrier may establish the factors to be considered by the committee in determining whether an application is complete and whether to accept or reject a complete application.

1. The factors considered by the committee shall be in writing, and shall be available for review by applicants upon request.

2. The formulas or methods of weighting of factors as specified by the carrier shall be confidential information.

(d) The carrier may establish its own application forms, but if it does not elect to establish its own form, the carrier shall make available, upon request, a written notice of the information it requires to be submitted to determine an application is complete.

(e) All applications, notices and guidelines required by this section shall be reviewable upon request by the Department.

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