N.J. Admin. Code § 11:22-1.11

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:22-1.11 - Internal appeals-dental plan organizations and dental service corporations

(a) Every dental plan organization and dental service corporation shall establish an internal appeals mechanism to resolve disputes between dental carriers or their agents and participating health care providers relating to payment of claims for services or supplies covered by a dental plan. The internal appeal mechanism shall be described in the participating provider contract.

1. The internal review shall be conducted by employees of the dental carrier who shall be personnel other than those responsible for claims payment on a day-to-day basis and shall be provided at no cost to the provider.

2. The internal review shall be conducted and its results communicated in a written decision to the provider within 30 days of receipt of the appeal. The written decision shall include:

i. The names, titles, and qualifying credentials of the persons participating in the internal review;

ii. A statement of the participating provider's grievance;

iii. The decision of the reviewers, along with a detailed explanation of the contractual and/or medical basis for such decision;

iv. A description of the evidence or documentation which supports the decision; and

v. If the decision is adverse, a description of the method to obtain an external review of the decision.

N.J. Admin. Code § 11:22-1.11

Reserved by 50 N.J.R. 571(a), effective 1/16/2018

Adopted by 50 N.J.R. 829(a), effective 2/5/2018