Current through Register Vol. 56, No. 24, December 18, 2024
(a)
Group policies and certificates providing health insurance in which some
portion of the benefits are subject to pre-authorization provisions shall
comply with the following:
1. There shall be
a caption for the pre-authorization provision in both the policies and
certificates that shall clearly state in prominent boldface type that benefits
will be reduced for noncompliance with the requirements of the
pre-authorization provision.
2. The
pre-authorization provision shall include a process by which a covered person
shall be able to appeal benefit denials (including, but not limited to,
hospitalization admission denials, a reduction of benefits payable, rejected
admissions and non-reviewed admissions), which process shall be described in
detail and shall state a reasonable time period within which the covered person
may expect the insurer (or any entity with which the insurer has contracted to
perform such reviews on its behalf) to respond.
3. The penalty for noncompliance shall not
exceed 50 percent of the charges which would otherwise be covered under the
contract, policy or certificate. Schedules of penalties to be offered to
policyholders (outlining the range of penalties for non-compliance with the
pre-authorization provision) shall be submitted to the Department with the
policy form filing.
4. If the
pre-authorization provision incorporates an emergency treatment
post-notification requirement with a notice deadline and penalty, the provision
shall include a statement that post-deadline notice shall be accepted and the
penalty waived if the covered person provides notification as soon as
reasonably possible.
5. Inpatient
and/or outpatient treatment for alcoholism as described at
N.J.S.A. 17B:27-46.1 shall only be subject
to pre-authorization provisions if all inpatient and/or outpatient treatments
for other injuries and illnesses are subject to the same review.
(b) Incorporation of the required
pre-authorization warning text in a certificate booklet, through certificate
riders and/or insert pages shall not be acceptable.
(c) If an identification card is used for
benefit certification purposes, a pre-authorization requirement warning similar
to that contained in the policy and certificate shall be displayed on the
identification card, along with a telephone number by which to contact the
insurer regarding the pre-authorization provision.
1. A sample of the identification card along
with a copy of any promotional and/or informational material which describes
the preauthorization requirement shall be included with the initial form
submission made to the Department.
