New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 23 - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT COVERAGE
Section 11:4-23.10 - Standards for claims payment
Universal Citation: NJ Admin Code 11:4-23.10
Current through Register Vol. 56, No. 24, December 18, 2024
(a) Every carrier providing Medicare supplement policies and certificates shall comply with Section 1882(c)(3) of the Social Security Act as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 ( P.L. 100-203) by:
1. Acceptance of notice from a
Medicare-Carrier on dually assigned claims submitted by participating
physicians and suppliers as a claim for benefits under the Medicare supplement
policy or certificate as sufficient claim notice without requiring other or
additional claims forms to be submitted, and making a payment determination
based on the information contained in the notice from the
Medicare-Carrier;
2. Notification
of the participating physician or supplier, and the beneficiary, of the payment
determination, and making payment directly to the participating physician or
supplier;
3. Providing each
enrollee, at the time of enrollment, a card listing the policy name, policy
number, and a mailing address to which notices from a Medicare-Carrier may be
sent;
4. Payment of user fees for
claim notices that are transmitted electronically or otherwise; and
5. Providing to the Secretary of Health and
Human Services at least annually, a central mailing address to which all claims
may be sent by the Medicare-Carrier.
(b) Compliance with the requirements set forth in (a) above shall be certified on the Medicare supplement experience reporting form.
(c) Payment of benefits for Medicare eligible expenses shall be conditioned upon the same or less restrictive payment conditions, including determinations of medical necessity, as are applicable to Medicare claims.
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