N.J. Admin. Code § 11:16-6.7

Current through Register Vol. 56, No. 23, December 2, 2024

Section 11:16-6.7 - Referrals to the Bureau and the OIFP

(a) The plan shall provide that upon completion of its investigation, as described in (d) below, an SIU shall refer cases which meet the standards in (a)1 and 2 below. The SIU shall submit one copy of the appropriate referral form and one copy of any attachments to the address indicated on the form. Submission of one copy of the referral form and attachments shall constitute a referral to both the Bureau and OIFP.

1. Any application or claim where the facts and circumstances create a reasonable suspicion that a person or entity has violated 17:33A-4; and

2. There is sufficient independent evidence corroborating the reasonable suspicion described in (a)1 above, from which a person could reasonably conclude that the person or entity has violated 17:33A-4.

(b) The facts and circumstances referred to in (a)1 above can include, but are not limited to, "fraud indicators" contained in an insurer's approved plan, and such other facts and circumstances as would lead a reasonable person to suspect that a violation of 17:33A-4 has occurred.

(c) As referred to in (a)2 above, independent evidence corroborating the reasonable suspicion that a person has violated 17:33A-4 includes, but is not limited to:

1. A statement from a witness;

2. Documentary evidence that directly negates a material element of the claim or directly establishes the falsity of a material element of an insurance application;

3. A report of an expert; or

4. Additional apparent misrepresentations tending to negate a possibility that the misrepresentation was merely an error.

(d) An investigation shall be complete for purposes of referral to the Bureau and OIFP when reasonable and appropriate investigative leads and opportunities have been exhausted. When an investigation has identified a pattern of possible violations of 17:33A-4, the investigation will be deemed complete for purposes of referral as a case to the Bureau and OIFP when one or more violations included in the identified pattern have been sufficiently investigated and corroborated, in accordance with (a) above for referral to the Bureau and OIFP.

N.J. Admin. Code § 11:16-6.7

Amended by R.2001 d.76, effective 3/5/2001.
See: 32 N.J.R. 4197(a), 33 N.J.R. 804(a).
In (a), inserted "OIFP-3A or OIFP-3B" preceding "which meet".
Amended by R.2006 d.308, effective 9/5/2006.
See: 38 N.J.R. 1276(a), 38 N.J.R. 3592(a).
Rewrote introductory paragraph of (a).
Amended by R.2014 d.035, effective 2/18/2014.
See: 45 N.J.R. 1989(a), 46 N.J.R. 358(a).
Section was "Referrals to OIFP". Rewrote the introductory paragraph of (a); and in (d), inserted "the Bureau and" three times.