New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24B - ORGANIZED DELIVERY SYSTEMS
Subchapter 4 - MANAGEMENT AGREEMENTS WITH CARRIERS
Section 11:24B-4.6 - Utilization management guidelines development
Current through Register Vol. 56, No. 6, March 18, 2024
(a) The contract shall detail the services that the ODS is performing on behalf of the carrier, specifying the general areas of health care services for which the UM guidelines are being developed or maintained.
(b) The contract shall specify that the ODS is obligated to assure and provide demonstration of involvement of practicing physicians and other licensed providers in the development and review of UM guidelines.
(c) If one or more of the health benefits plans of the carrier with which the ODS will contract is a managed care plan, the management agreement shall specify that the ODS is obligated to establish a mechanism for providers in the carrier's network, or in the network(s) with which the carrier contracts, to review and provide comment on the UM guidelines established by the ODS and be able to demonstrate compliance with this requirement.