Current through Register Vol. 56, No. 6, March
18, 2024
(a) In order to
qualify for certification to perform network management, an ODS shall comply
with the requirements of
11:24B-3.4(b),
and shall perform the following duties, meeting the standards of this section:
1. Recruiting, and maintenance of provider
relations systems, in order to assure constant network adequacy with respect to
the categories of providers to be included in the ODS' network;
2. Implementation and maintenance of a
provider participation panel for the ODS' network;
3. Implementation and maintenance of a
credentialing and recredentialing mechanism for the ODS' network;
4. Implementation and maintenance of a
provider notice and termination hearing mechanism for the ODS'
network;
5. Implementation and
maintenance of a complaint mechanism for providers in the ODS'
network;
6. Designation of a
medical director licensed to practice medicine in New Jersey; and
7. Implementation and maintenance of a
continuous quality improvement program for the ODS' network.
(b) With respect to network
adequacy, the ODS shall assure that the network meets the standards for
determining network adequacy as set forth at
11:24A-4.1 0 or 11:24-6 for those
categories of providers in the ODS' network with respect to those services that
the providers are required to render.
1. If
an ODS is not arranging for the provision of the carrier's entire network, the
ODS shall include a statement to this effect in its demonstration, and shall
specify the providers for which the ODS is agreeing to be responsible, the
geographic location for which the ODS is agreeing to be responsible, and any
other limitations that may be applicable to the ODS network.
(c) An ODS shall either designate
a medical director for its network who is licensed to practice medicine in New
Jersey and who shall be responsible for the following functions, or the ODS
shall demonstrate that the medical director of the carrier is licensed to
practice medicine in New Jersey, and that the carrier's medical director shall
have ultimate oversight of the ODS' network with respect to the carrier's
health benefits plans, including, but not necessarily limited to, the following
functions:
1. Credentialing in accordance
with 11:24-4.2(a)7 or
11:24A-4.5(c)4;
2. Oversight of professional services, staff
and education in accordance with
11:24-4.2(a)1
through 4, or 11:24A-4.5(c)1 through 3 and 11:24A-3.3(b)1;
3. Providing direction and leadership to the
continuous quality improvement program in accordance with
11:24-4.2(a)5 or
11:24A-3.3(b)2;
4. Establishing policies and procedures
covering all health care services to be provided through the ODS' network to
covered persons in accordance with
11:24-4.2(a)6 or
11:24A-3.3(b)3;
and
5. Implementing or coordinating
with the carrier on a procedure that provides participating providers an
opportunity to review and comment on all medical, surgical and/or dental
protocols applicable to the area of practice of the provider in accordance with
11:24-4.2(a)8 or
11:24A-4.5(c)5.
(d) The ODS shall demonstrate that
its provider participation panel is in compliance with either
11:24A-4.7 or
11:24-3.9.
1. The provider participation panel and
processes related thereto shall be for the purposes of participation in the
ODS' network, and shall not be a substitute for provider participation
requirements applicable to carriers.
(e) The ODS shall demonstrate that its
provider termination hearing process is in compliance with either
11:24A-4.9 or
11:24-3.6.
1. The provider termination rights and
hearing process shall be for the purposes of termination from the ODS' network,
and shall not be a substitute for provider termination requirements applicable
to carriers.
(f) The ODS
shall demonstrate that it shall comply with the standards for provider
termination established at either
11:24A-4.8 or
11:24-3.5 with respect to the
continuing obligations and rights of health care providers to provide patient
care, regardless of whether the provider is terminated from the ODS network by
the ODS, or from the carrier's network by the carrier.
(g) The ODS shall demonstrate that its
complaint processing system for providers is in compliance with the standards
at 11:24A-4.6(b) and
(e), or
11:24-3.7(b) and
(e).
(h) The ODS shall demonstrate that it has a
continuous quality improvement program in place, setting forth the scope of the
program, and addressing at least the following:
1. The duties and responsibilities of the
ODS' medical director, or the medical director of the carrier with respect to
the ODS' CQI program;
2. The
contractual arrangements, if any, for delegation of quality improvement
activities;
3. Confidentiality
policies and procedures;
4.
Specification of standards of care, criteria and procedures for the assessment
of the quality of services provided by the providers in the ODS' network, and
the adequacy and appropriateness of health care resources utilized;
5. A system of ongoing evaluation activities,
including individual case reviews as well as pattern analysis;
6. A system of focused evaluation activities,
particularly for frequently performed and/or highly specialized procedures,
regardless of the type of provider network, or services provided by the
network;
7. A system for monitoring
the ODS' network providers' response and feedback on the ODS' operations, and
the providers' perceptions of the operations of the carriers with which the ODS
contracts;
8. The procedures for
conducting peer review activities by providers within the same discipline and
area of clinical practice;
9. A
system for evaluating the effectiveness of the continuous quality improvement
program;
10. A system for linking
the continuous quality improvement program of the ODS with the continuous
quality improvement programs of the carriers with which the ODS contracts, with
timely and appropriate transfer of information between the contracted
parties;
11. The establishment of a
multidisciplinary committee that includes representation from among the
providers in the network, administrative staff of the ODS, representation by
the carriers with which the ODS is contracted, and nursing staff, if the ODS
has nursing staff available to it, which shall be responsible for the
implementation and operations of the continuous quality improvement program,
including the linkage of the program with the carrier contractors, pursuant to
(h)10 above;
i. An ODS may satisfy this
requirement by demonstrating participation at multidisciplinary committees
established and maintained by the separate contracting carriers, if the ODS is
also able to demonstrate that it has in place and utilizes a mechanism for
collecting and bringing the points of view of its participating providers to
the attention of the multidisciplinary committees on relevant issues;
and
12. The
establishment of a system for keeping the board of directors or executive
committee of the ODS informed of the continuous quality improvement activities,
including at least an annual written report delineating quality improvements,
performance measures used and their results, and demonstrated improvements in
clinical and services quality.
(i) With respect to the continuous quality
improvement program of (h) above:
1. If the
ODS provides or arranges for the provision of substantially all of the services
that a carrier has agreed to cover or make payment of benefits for under the
carrier's health benefits plan(s), the ODS' continuous quality improvement
program's monitoring of the availability, accessibility, continuity and quality
of care shall include at least:
i. A
mechanism for monitoring patient appointments and triage procedures, discharge
planning services, linkage between all modes and levels of care and
appropriateness of specific diagnostic and therapeutic procedures selected by
the continuous quality improvement committee;
ii. A mechanism for evaluating all of the
network providers, including health care facilities.
(1) A health care facility's internal quality
assurance program shall not constitute the only assessment of patient care by
the ODS; and
iii. A
system to monitor both provider and covered person access to utilization
management services, when ODS agreed to perform any utilization management
function for the carrier.
2. In determining if an ODS' network provides
or arranges for the provision of performance of substantially all of the health
care services covered under a carrier's health benefits plan(s), or for which
the carrier has agreed to pay benefits under its health benefits plan(s), the
Department shall not take into consideration whether the ODS provides or makes
arrangement for the provision of pharmaceutical services, behavioral health
services, case management, disease management, utilization management, or
durable medical equipment, but shall take into consideration whether the ODS
provides or arranges for the provision of preventive and primary medical care
services, specialty medical and ancillary care services, inpatient services,
nursing services, and rehabilitative services.
