N.J. Admin. Code § 11:24-3.6

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

Section 11:24-3.6 - Hearings for provider terminations

(a) A health care professional shall have the right to request in writing a hearing within 10 business days following the date of receipt of notice of termination of the health care professional occurring prior to the date of termination from an HMO's network stated in the provider agreement.

1. A contract shall be deemed to have terminated, creating the right to a hearing, whenever a contract terminates on any date other than a designated renewal or anniversary date of the contract, except that no such right shall exist with respect to terminations described at 11:24-3.5(a)1 ii.

2. If no renewal or anniversary date is specified in the contract, then the renewal or anniversary date shall be deemed to be the month and day in each calendar year on which the contract was originally signed by both parties, or become effective, whichever date is latest.

(b) The HMO shall hold a hearing within 30 days following receipt of a written request for a hearing by a terminated health care professional before a panel appointed by the HMO.

1. The panel shall consist of no less than three people.

2. At least one person on the panel shall be a clinical peer in the same or substantially similar discipline and specialty as the provider requesting the hearing.

3. The HMO shall not preclude the provider from being present at the hearing, nor shall the HMO preclude the provider from being represented by counsel at the hearing.

(c) The panel shall render a decision on the matter in writing within 30 days of the close of the hearing unless the panel provides notice of a need for an extension for the rendering of its decisions to both the HMO and the health care professional prior to the date the panel's decision would otherwise be due.

1. The panel's decision shall set forth the relevant contract provisions and the facts upon which the HMO and the provider have relied at the hearing.

2. The panel shall recommend that the provider be terminated, reinstated or provisionally reinstated.

3. The panel shall specify its reasons for its recommendations, including the reasons for any conditions for provisional reinstatement.

4. The panel shall specify the conditions for provisional reinstatement, the duration of the conditions, and the consequences of a failure to meet the conditions.

5. In the event of reinstatement or provisional reinstatement, the panel shall specify the impact of the reinstatement upon the terms of duration of the contract at issue.

(d) In the event that the panel recommends that the health care professional be terminated, the HMO shall then provide notice of the termination to members in accordance with 11:24-3.5(b).

N.J. Admin. Code § 11:24-3.6

New Rule, R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
Former N.J.A.C. 8:38-3.6, Complaint and appeal system, recodified to N.J.A.C. 8:38-3.7.