N.J. Admin. Code § 11:22-1.14

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

Section 11:22-1.14 - Reporting requirements

(a) A carrier or ODS shall report to the Department on a quarterly and annual basis on the timeliness of claims payments and on the reasons for denial and late payment of claims in a format set forth by bulletin or similar means and/or on the Department's website. Due dates for the reports are as follows: May 15 for the first quarter; August 15 for the second quarter; November 15 for the third quarter; and March 31 for the annual report.

(b) The annual report on the timeliness of claims payments and on the reasons for denial and late payment of claims shall be audited by a private auditing firm at the expense of the carrier or ODS. The annual report shall be accompanied by the report of the auditing firm that reviewed the report. In addition to the Department, copies of the audited annual report shall be sent to the Governor and the majority and minority offices of the Legislature.

(c) The report shall be submitted by the due date to:

New Jersey Department of Banking and Insurance

Life & Health Actuarial, 11th Floor

Prompt Payment Reports

20 West State Street (for private Express Delivery)

PO Box 325 (for regular US mail)

Trenton, New Jersey 08625-0325

(d) All quarterly reports shall be submitted by the due date as an Excel spreadsheet through the State Electronic Rate and Form Filing System.

(e) A carrier or ODS may request an exemption from the requirements to have the annual report audited and to submit a report of the auditing firm. This exemption must be obtained on an annual basis. Such an exemption may be granted if the carrier or ODS meets the following conditions:

1. The carrier or ODS must file the annual report in a timely manner. The report shall be accompanied by a request for exemption from the requirements that the report be audited and that a report of the auditing firm be submitted; and

2. The annual premiums earned by the carrier or ODS in New Jersey for all health benefits plans as defined in 11:22-1.2 were less than $ 5 million in the year covered by the annual report for which the exemption is requested. The carrier or ODS shall provide, in its request for exemption, a copy of the report of net earned premiums submitted to the Commissioner pursuant to 11:4-23A.8(a)1 or, alternatively, other evidence acceptable to the Commissioner that premiums are less than $ 5 million.

(f) After the Commissioner has reviewed the annual report and the request for exemption, the Commissioner shall either grant or disapprove the request. Any request meeting the conditions of (e) above shall be deemed granted 30 days after its receipt by the Commissioner unless disapproved. The Commissioner may disapprove a request for one or more of the following reasons:

1. The request does not meet the enumerated conditions of (e) above;

2. The carrier or ODS has not filed a report, made a refund, or paid an assessment required by law applicable to a carrier or ODS; or

3. The Commissioner finds that an audit is necessary to verify the accuracy of the report or to otherwise meet the purposes of 11:22-1.14 and 17B:30-12 et seq.

(g) A carrier or ODS which has obtained an exemption from filing an audited annual report under (e) and (f) above shall also be exempt from filing quarterly reports for the year following the year for which the exemption was obtained. If the carrier or ODS seeks an exemption from filing an audited annual report for the year following the year for which such an exemption was previously obtained, a separate request for an exemption shall be required for the audited annual report for that ensuing year.

N.J. Admin. Code § 11:22-1.14

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

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