N.J. Admin. Code § 11:22-1.16

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

Section 11:22-1.16 - Explanation of benefits

(a) Every carrier shall provide an explanation of benefits, within 30 days if the claim is filed electronically or 40 days if a claim is submitted in writing, to covered persons in response to the filing of a claim by a provider or a covered person under a health benefits plan.

(b) The explanation of benefits shall include at least the following information:

1. Name of the covered person;

2. Name of the provider;

3. Date of service;

4. Clear description of the service;

5. Billed charge;

6. Allowed charge;

7. Non-covered amount;

8. A specific explanation of why a charge is not covered by the health benefits plan, for example, person not covered on date of service, provider not in network, other coverage is primary, the service is not medically necessary, no prior authorization, no referral, experimental or investigational service, or service is excluded by contract. Use of denial reasons with multiple grounds shall only be used if each denial ground applies to the specific claim, including when the reasons are separated by an "and," similar text, symbol, or punctuation;

9. The amount that is the covered person's responsibility due to deductible, coinsurance, and copayment;

10. The accumulation toward the covered person's deductible, or family deductible, if applicable;

11. The accumulation toward the covered person's maximum out-of-pocket, or family maximum out-of-pocket, if applicable;

12. Amount paid by plan, interest should be shown separately if interest is paid;

13. An explanation of the process to appeal the determination on the claim; and

14. A telephone number that the covered person can call to get additional information on the processing of the claim.

(c) If review of the claim is still pending upon issuance of the EOB, the EOB shall so state and (b)6 through 10 above can be omitted.

N.J. Admin. Code § 11:22-1.16

Recodified from 11:22-1.5 by 50 N.J.R. 571(a), effective 1/16/2018