N.J. Admin. Code § 11:22-1.13

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

Section 11:22-1.13 - External appeals-health carriers-arbitration

(a) Any dispute regarding the determination of an internal appeal conducted pursuant to a health carrier's or its agent's internal appeal mechanism established pursuant to P.L. 2005, c. 352, and described at 11:22-1.10, may be referred to arbitration, except for the following disputes that are eligible to be submitted to the Independent Health Care Appeals Program established pursuant to 26:2S-11. The disputes shall involve whether:

1. A treatment or service is medically necessary;

2. A treatment or service is experimental or investigational;

3. A treatment or service is cosmetic;

4. A treatment or service is medical or dental;

5. A condition is a preexisting condition; and

6. The health carrier should authorize services to be performed by an out-of-network provider but hold the member responsible for in-network cost sharing only because the carrier's network lacks a provider who is accessible and possesses the requisite skill and expertise to perform the needed services.

(b) Any provider involved in a payment dispute for which any determination was made by a health carrier's or its agent's internal appeal mechanism created pursuant to P.L. 2005, c. 352, and described at 11:22-1.10, may initiate an arbitration proceeding within 90 calendar days of the receipt of the determination on the internal appeal.

(c) A provider who has not been notified by a health carrier or its agent within 30 days of the carrier's or its agent's receipt of an appeal to be conducted pursuant to the internal appeal mechanism created by P.L. 2005, c. 352, and described at 11:22-1.10, may initiate an arbitration proceeding within 90 days of the carrier's or its agent's missed due date for the determination on the internal appeal.

(d) A provider shall initiate an arbitration proceeding by submitting a complete Arbitration Request Application directly to the arbitration organization with which the Department has contracted pursuant to P.L. 2005, c. 352.

(e) Upon receipt of an Arbitration Request Application, the arbitration organization, or the Department, at its option, shall review the application and make a determination regarding the eligibility of the claim(s) for arbitration and completeness of the application. The arbitration organization, or the Department, if applicable, shall accept for processing a complete application that meets the following criteria:

1. The covered person's health benefits or prescription drug plan under which the payment dispute has arisen, was delivered, or issued for delivery in New Jersey, and is not an out-of-State plan, a self-funded plan, or a Federal plan, except for Managed Medicaid;

2. The disputed claim amount shall be $ 1,000 or more, including any aggregation of claims;

3. The provider initiating the arbitration request shall have rendered a covered service to a covered person under the health benefits plan at the time of the action on which the arbitration is based;

4. The service that is the subject of the arbitration request reasonably appears to be a covered service under the health benefits or prescription drug plan that covers the covered person, and the covered person was enrolled in the plan at the time the service was rendered or the supply provided;

5. The application includes, or the covered person has previously submitted, a fully-executed Consent to Release of Medical Records for Claim Payment and Arbitration form signed by the covered person in the event that the covered person's confidential information accompanies the arbitration request, which provides a patient with the opportunity to consent to representation in utilization management appeals and to provide authorization to release information in utilization appeals and arbitration of claims and to revoke such consent and which form can be accessed on the Department's website at http://www.state.nj.us/dobi/chap352/352implementnotice.html; and

6. The provider initiating the arbitration request has submitted to the arbitration organization all information requested by the arbitration organization as necessary to conduct the arbitration proceeding in addition to the Request for Arbitration Application.

(f) The arbitration organization shall reject an Arbitration Request Application received in excess of 90 days after the provider's receipt of the health carrier's or its agent's written determination on the internal appeal conducted pursuant to the internal appeal mechanism created by P.L. 2005, c. 352, and described at 11:22-1.10, or in excess of 90 calendar days after a health carrier's or its agent's missed due date for the written determination of the provider's internal appeal conducted pursuant to the internal appeal mechanism created by P.L. 2005, c. 352, and described at 11:22-1.10.

(g) Within five business days of receipt of the Arbitration Request Application, the arbitration organization shall acknowledge receipt of the application to the health carrier or its agent and the provider and provide notice of any deficiencies in the application or accompanying documents and of the procedure for correcting the deficiencies.

(h) If a provider fails to correct any deficiencies within 15 days of receipt of notice, the Arbitration Request Application shall be deemed withdrawn.

(i) If an arbitration request is rejected in whole or in part based on information submitted with the provider's Arbitration Request Application, the arbitration organization shall retain the provider's review fee and refund the arbitration fee. If the request for arbitration is initially accepted, but later rejected as ineligible for arbitration based on information submitted in whole or in part by the health carrier or its agent, the arbitration organization shall retain the review fees of both the provider and the health carrier or its agent and refund the arbitration fees.

(j) Within 30 days of receipt of a complete Arbitration Request Application and accompanying documents as set forth in (e) above, the arbitrator shall issue a written decision addressing whether the provider requesting the arbitration was properly or improperly reimbursed for the claim(s) by the health carrier or its agent.

(k) The arbitration proceeding shall be conducted pursuant to the rules of the arbitration organization, including rules of discovery subject to confidentiality requirements established by State and Federal law.

(l) The arbitration proceeding shall be limited to only the issue(s) in dispute for which the Request for Arbitration Application was made and accepted by the arbitration organization.

(m) The only evidence admissible in an arbitration proceeding or on which the arbitrator's determination may be made are the documents submitted to, requested by, and accepted by, the arbitration organization by either the provider or the health carrier or its agent involved in the payment dispute. In-person or telephonic testimony shall not be permitted.

(n) The arbitrator shall issue a signed, written determination of the payment dispute, which shall explain each and every basis of the determination, and shall include, but not be limited to, a full and complete statement of the following:

1. The issue(s) in dispute;

2. Findings of fact;

3. Conclusions on which the determination was based, including all evidence relied on in support thereof; and

4. The amount of the award, if any, including interest, with the amount of the interest specified.

(o) The arbitrator's determination shall be nonappealable and binding on all parties to the payment dispute. The arbitrator's determination and/or award may be vacated or modified only in accordance with 2A:24-1 et seq.

(p) If the arbitrator determines that a health carrier or its agent has erroneously withheld or denied payment of a claim, the arbitrator shall order the health carrier or its agent to make payment of the claim on or before the 10th business day following the issuance of the determination, together with interest at the rate of 12 percent per annum accruing from the date the appeal was received by the health carrier or its agent for resolution through the internal appeal process or, if that date is unknown, from 45 days prior to the date of filing the Request for Arbitration Application. If the arbitrator determines that a health carrier or its agent has withheld or denied payment on the basis that information requested by the health carrier or its agent was not submitted by the provider when the claim was initially processed by the health carrier or its agent or reviewed by the health carrier or its agent pursuant to its internal appeal process, the health carrier or its agent shall not be required to pay any accrued interest.

(q) If the arbitrator determines that a provider has engaged in a pattern and practice of improper billing and a refund is due to the health carrier or its agent, the arbitrator may award the health carrier or its agent a refund, including interest accrued at the rate of 12 percent per annum. Interest shall begin to accrue on the date the appeal was received by the health carrier or its agent for resolution through the internal appeal process described at 11:22-1.10.

(r) The arbitrator shall not award legal fees or costs.

N.J. Admin. Code § 11:22-1.13

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

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