New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 37 - SELECTIVE CONTRACTING ARRANGEMENTS OF INSURERS
Section 11:4-37.4 - Selective contracting arrangement approval and amendment procedures
Current through Register Vol. 56, No. 6, March 18, 2024
(a) No carrier shall issue health benefits plans utilizing selective contracting arrangements unless the carrier has entered into such arrangements directly with network providers or has contracted with a licensed or certified ODS, an HMO, or a PPO for prescription drug benefits.
(b) For the purposes of obtaining the Commissioner's approval under this subchapter, a carrier issuing health benefit plans utilizing a selective contracting arrangement shall submit four copies of a complete selective contracting arrangement approval application on a form to be provided by the Department.
(c) A complete selective contracting arrangement approval application shall include the following:
Provider agrees that in no event, including but not limited to nonpayment by the health carrier or intermediary, payment by the health carrier or intermediary that is other than what the provider believed to be in accordance with the reimbursement provision of the provider agreement or is otherwise inadequate, insolvency of the health carrier or intermediary, or breach of this agreement, shall the provider bill, charge or collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a covered person or a person (other than the health carrier or intermediary) acting on behalf of the covered person for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of coverage. Nor does this agreement prohibit a provider (except for a health care professional who is employed full-time on the staff of a health carrier and has agreed to provide services exclusively to that health carrier's covered persons and no others) and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific service or services.
(d) The Commissioner, in consultation with the Commissioner of Health and Senior Services as necessary, shall review these documents and grant approval, within 60 days of the carrier's filing its complete application to those carriers whose selective contracting arrangements are determined to meet the criteria set forth in this subchapter. The Commissioner shall notify a carrier of any deficiencies in its application within the 60-day period and the carrier shall have 60 days from such notice to respond to the deficiency notice. Carriers that do not respond within the 60-day period shall have their applications deemed withdrawn. A final decision to deny approval shall be accompanied by a written explanation by the Department of the reasons for denial. A carrier whose selective contracting arrangement has been denied approval may request an administrative hearing pursuant to the procedures at 11:4-37.5.
(e) A carrier shall complete an annual report on a form provided by the Commissioner. The report shall be submitted to the Department no later than May 1 of each year, and shall include information for the previous calendar year regarding membership, number of employer contracts and plan experience.
(f) In addition to the requirements set forth in this section, a carrier contracting directly with network providers shall comply with the requirements set forth at N.J.A.C. 11:24C-4.