New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS
Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS
Section 11:6-2.7 - Approval suspension and revocation

Universal Citation: NJ Admin Code 11:6-2.7

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The Commissioner shall approve an application if he or she finds that the applicant meets the following standards:

1. All of the materials required by this chapter or by the Commissioner have been filed;

2. The persons responsible for conducting the applicant's affairs are competent, trustworthy, possess good reputations, and have appropriate experience, training and education;

3. The applicant has demonstrated the ability to assure that its services will be performed in a manner which will ensure the efficient operation of its business, including appropriate financial controls;

4. The required programs to be used by the applicant are acceptable; and

5. The compensation arrangements made between the applicant and the benefits payer do not result in the assumption of financial risk by the applicant.

(b) The approval of an WCMCO issued by the Department under this subchapter may be suspended or revoked if:

1. The Department determines that the WCMCO criteria set forth in this subchapter are no longer being met;

2. Service under the plan is not being provided in accordance with the terms of the approved plan;

3. The plan for providing medical services fails to meet the requirements of these rules;

4. Any false or misleading information is submitted by the WCMCO or any member of the organization;

5. The approved WCMCO continues to utilize the services of a medical service provider whose license has been suspended or revoked by the licensing board; or

6. The approved WCMCO fails to reduce losses sufficiently to produce a five percent premium credit.

(c) If the Commissioner denies WCMCO approval under this subchapter or suspends or revokes WCMCO approval for any of the reasons set forth in this subsection, the WCMCO may request a hearing on the Commissioner's determination within 10 days from the date of receipt of such determination.

1. A request for a hearing shall be in writing and shall include:
i. The name, address and telephone number of a contact person familiar with the matter;

ii. A copy of the Commissioner's written determination;

iii. A statement requesting a hearing; and

iv. A concise statement describing the basis for which the WCMCO believes that the Commissioner's findings of fact are erroneous.

2. The Commissioner may, after receipt of a properly completed request for a hearing, provide an informal conference between the WCMCO and such personnel of the Department as the Commissioner may direct, to determine whether there are material issues of fact in dispute.

3. The Commissioner shall, within 30 days of a properly completed request for a hearing, determine whether the matter constitutes a contested case, pursuant to the Administrative Procedure Act, 52:14B-1 et seq.
i. If the Commissioner finds that there are no good-faith disputed issues of material fact and the matter may be decided on the documents filed, the Commissioner shall notify the WCMCO in writing of the final disposition of the matter.

ii. If the Commissioner finds that the matter constitutes a contested case, the Commissioner shall transmit the matter to the Office of Administrative Law for a hearing consistent with the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

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