Current through Register Vol. 56, No. 24, December 18, 2024
(a) The contract
shall detail the functions that the ODS is obligated to perform on behalf of
the carrier with respect to network management, including all health care
services and supplies the ODS will arrange to have provided to the carrier's
covered persons.
(b) The contract
shall specify the factors and thresholds that obligate the ODS to expand or
limit the number of providers within its network in order to assure that its
network meets the requirements of
N.J.A.C. 11:24-6.2 and 6.3, or 11:24-4.1 0,
as appropriate to the type(s) of providers in, and the health care services to
be offered through, the network and as appropriate to the type of carrier under
contract.
(c) The contract shall
specify the compensation arrangement between the ODS and the health care
providers in the network.
1. The compensation
arrangement shall not provide financial incentives to the providers for the
withholding of covered health care services that are medically necessary.
i. An ODS shall not be precluded from using
capitated payment arrangements between the ODS and a provider.
ii. Notwithstanding (c)1i above, an ODS shall
not use capitation as the sole method of reimbursement to providers who provide
primarily supplies (for instance, prescription drugs or durable medical
equipment) rather than services.
2. The provision shall specify the process by
which the ODS will make payment to providers, which shall be consistent with
the standards of
P.L.
1999, c. 154 (Health
Information Technology Act), as amended, as well as
P.L.
1999, c. 155, as
amended, and rules promulgated pursuant thereto, including N.J.A.C.
11:22-1.
(d) The
contract shall specify the utilization management standards that will apply to
the ODS' network.
1. If the provision does
not specify that the ODS shall assure compliance with the utilization
management standards of the carrier, then the provision shall specify that the
carrier adopts and takes responsibility for the utilization management
standards to be used by the ODS.
(e) The contract shall specify whether the
ODS is responsible for any portion of the utilization management review and
appeal process, and shall detail how the ODS and the carrier interact with
respect to UM and UM appeals.
(f)
The contract shall specify the circumstances under which a carrier may request
that the ODS remove a health care provider from participation in the network
and/or the carrier's product(s), and the standards applicable to such removal,
which shall be the equivalent of a termination of the provider from the
carrier's network.
1. With respect to
providers that are health care professionals, the contract shall specify that
the carrier shall provide the ODS with sufficient advance notice of the desire
to terminate the provider so that the health care professional receives at
least 90 days prior notice of the termination, and the right to request a
hearing, except when termination is:
i. Based
on a belief of the carrier that the provider has breached the terms of the
provider agreement;
ii. Based on a
belief of the carrier that the provider has engaged in fraud;
iii. Based on a belief of the carrier that
the provider is an imminent danger to one or more covered persons, or the
health, safety or welfare of the public, based on the opinion of the carrier's
medical director; or
iv. To occur
on the renewal date of the provider's contract, or the anniversary date of the
provider's contract, if no renewal date is specified.
2. With respect to providers that are health
care professionals, the contract shall specify that the carrier shall make
available to the provider, whether directly or through the ODS, a written
explanation of the reason for the termination upon request, if such written
explanation is not otherwise provided to the health care professional
automatically.
3. The contract
shall specify what criteria the ODS may request from the carrier in order to
effect a termination of the provider.
4. The contract may relieve the ODS of
complying with
N.J.S.A. 26:2S-8 and rules promulgated
pursuant thereto when the provider is terminated at the request of the carrier,
so long as it is stated in the contract that providers shall be directed to the
carrier in order to exercise their rights pursuant to
N.J.S.A. 26:2S-8.
5. The circumstances under which a carrier
may request termination of a provider shall not be based on the provider filing
complaints or appeals in his or her own behalf or on behalf of a covered
person, or otherwise acting as an advocate of a covered person in seeking
appropriate, medically necessary health care services covered by the covered
person's health benefits plan.
(g) The contract shall specify the
circumstances under which the ODS may terminate a provider from its network,
and the standards for notice to the carrier that the ODS shall provide prior to
effecting such a termination.
1. With respect
to a health care professional, the ODS shall provide the carrier with
sufficient notice so that the carrier's covered persons are afforded at least
30 days prior notice of the termination of the provider, except when:
i. The ODS believes that the provider has
breached the terms of the provider agreement;
ii. The ODS believes that the provider has
engaged in fraud; or
iii. The ODS
believes that the provider is an imminent danger to one or more covered
persons, or the health, safety or welfare of the public, based on the opinion
of the carrier's or the ODS' medical director.
2. The contract may relieve the carrier of
any obligation to comply with
N.J.S.A. 26:2S-8, and rules promulgated
pursuant thereto, when the provider is terminated upon the prerogative of the
ODS, so long as it is stated in the contract that providers shall be directed
to the ODS in order to exercise their rights pursuant to
N.J.S.A. 26:2S-8.
3. The circumstances under which an ODS may
terminate a provider shall not be based on the provider filing complaints or
appeals in his or her own behalf or on behalf of a covered person, or otherwise
acting as an advocate of a covered person in seeking appropriate, medically
necessary health care services covered by the covered person's health benefits
plan.
(h) The contract
shall include provisions obligating the ODS to assure that providers in the
network comply with the requirements of
N.J.S.A. 26:2S-9.1 and
26:2J-11.1, and rules promulgated
pursuant thereto, as appropriate to the type of provider and the carrier.
1. The obligation to assure that providers
comply with continuity of care requirements shall apply regardless of whether
the provider is terminated at the request of the carrier, at the prerogative of
the ODS, or at the option of the provider.
2. The obligation to assure that providers
comply with continuity of care requirements shall apply regardless of the
reason for the termination, except that the ODS and the carrier may agree that
the provider shall not be permitted to continue to provide care to a covered
person as if the provider were in-network if the provider has been terminated
on the basis of breach, fraud or imminent danger to a covered person, or the
health, safety or welfare of the public.
(i) The contract shall prohibit both the ODS
and the carrier from in any way discouraging open communication between
providers and the carrier's covered members regarding diagnostic tests and
treatment options, and shall specify that the ODS shall not penalize a provider
based on complaints or appeals made by the provider in his or her own behalf or
on behalf of a covered person, or for otherwise acting as an advocate of a
covered person in seeking appropriate, medically necessary health care services
covered under the covered person's health benefits plan.
(j) The contract shall require the ODS to
assure that its network providers will not bill, or otherwise pursue payment
from, a carrier's covered persons for the costs of services or supplies
rendered in-network that are covered, or for which benefits are payable, under
the covered person's health benefits plan, other than for copayments,
coinsurance or deductible amounts set forth in the health benefits plan,
regardless of whether the provider agrees with the amount paid, or to be paid,
by the ODS or carrier, as appropriate, for the services or supplies.
(k) The contract shall require the ODS to
assure that its network providers treat a carrier's members without
discrimination.
(l) The contract shall
specify the obligation of the ODS to assure that its network providers, if
primary care providers, make health care services available to a carrier's
covered person 24 hours per day, seven days per week.
(m) The contract shall specify the
obligations of the ODS with respect to implementation and maintenance of a
provider complaint and appeal mechanism, and shall detail the way in which the
ODS' complaint and appeal mechanism is coordinated with the carrier's
continuous quality improvement program.
(n) The contract shall specify the
obligations of the ODS with respect to implementation and maintenance of a
provider participation panel.
(o) The contract shall
specify the obligations of the ODS with respect to implementation and
maintenance of a credentialing program, and shall detail the way in which the
ODS' credentialing program is coordinated with the carrier's continuous quality
improvement program and complaint system(s).
(p) The contract shall specify the manner in
which the ODS' continuous quality improvement program and the carrier's
continuous quality improvement program coordinate, the information the ODS and
carrier are obligated to provide to one another, and the data that each is to
collect, including details regarding the timing of reports and information
transfers.
