N.J. Admin. Code § 11:24B-5.3

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

Section 11:24B-5.3 - Termination and continuity of care standards for contracts with health care professionals

(a) Provider agreements shall specify the term of the contract, reasons for which the contract may be terminated by one or more parties to the contract, procedures for notice and effectuation of such termination, and opportunities, if any, to cure any deficiencies prior to termination.

1. If the reason(s) for which a provider may be terminated from the ODS' network is different from the reason(s) for which a provider may be removed from participation in a carrier's panel, the contract shall so specify this.

2. If the contract permits a provider to elect not to participate in a carrier's panel without also terminating the provider agreement with the ODS, the contract shall contain a provision setting forth the standards and procedures for this.

(b) The provider agreement may specify that the contract may be terminated without cause, so long as non-cause termination is permitted by either party subject to reasonable prior notice and the terms of the provision otherwise comply with the remainder of this section.

(c) The contract shall stipulate that, when the provider's status as a participating provider in a carrier's network is being terminated, written notice shall be issued to the provider no less than 90 days prior to the date of termination, except that the 90-day prior notice requirement need not apply when the contract is being terminated upon its date of renewal, or upon its anniversary date, if no annual renewal date is specified, or is being terminated because of breach, alleged fraud, or because, in the opinion of the medical director of either the ODS or the carrier, if different, the health care professional presents an imminent danger to one or more covered persons, or the public health, safety or welfare.

1. The contract shall specify that the health care professional shall receive a written statement setting forth the reason(s) for the termination, and the procedures for obtaining such a written statement, in the event that the written notice of termination does not include a statement setting forth the reason(s) for the termination.

(d) The contract shall stipulate that the health care professional shall have the right to request a hearing following a notice that the health care professional's status as a participating provider with a carrier is being terminated, except that the contract may specify that the right to a hearing does not apply when the termination occurs on the date of renewal of the contract, or upon the contract's anniversary date, if no annual renewal date is specified, or termination is based on breach or alleged fraud, or because, in the opinion of the medical director of either the ODS or the carrier, if different, the health care professional presents an imminent danger to one or more covered persons, or the public health, safety or welfare.

(e) The contract shall specify the procedures for requesting a hearing from a carrier when a health care professional is terminated from participation in the carrier's network, which shall be consistent with the requirements of 11:24-3.6 or 11:24A-4.9, as appropriate.

(f) The contract shall specify that when a provider's status as a participating provider is terminated, or when the contract between the ODS and the provider terminates, regardless of the party initiating the termination, the provider, if a physician, shall remain obligated to provide services for covered persons in accordance with the following:

1. For up to four months following the effective date of the termination in cases where it is medically necessary for the covered person to continue treatment with the health care professional, except as (f)2 through 5 below applies;

2. In cases of the pregnancy of a covered person, through the postpartum evaluation of the covered person, up to six weeks after delivery;

3. In the case of post-operative care, up to six months following the effective date of the termination;

4. In the case of oncological treatment, up to one year following the effective date of the termination; and

5. In the case of psychiatric treatment, up to one year following the effective date of the termination.

(g) Notwithstanding (f) above, the contract may specify an exception to the requirement for the provider to continue to provide care, and for the ODS or carrier to pay for services rendered by the provider following the effective date of termination when the termination is based on breach or alleged fraud, or because, in the opinion of the medical director of either the ODS or the carrier, if different, the health care professional presents an imminent danger to one or more covered persons, or the public health, safety or welfare.

N.J. Admin. Code § 11:24B-5.3