N.J. Admin. Code § 11:24A-5.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24A-5.1 - General requirements

(a) The Department shall be responsible for the operation of the Independent Health Care Appeals Program.

1. The Department shall combine the Independent Health Care Appeals Program with the External Appeals program set forth under N.J.A.C. 11:24-8.7, but, in accordance with the Administrative Procedures Act, N.J.S.A. 52:14B-1 et seq., may amend the standards set forth at N.J.A.C. 11:24-8.7 as necessary to make the appeal process more effective for covered persons insured through contracts or policies of carriers that are not HMOs.

2. The general qualifications of and standards of practice for IUROs participating in the Independent Health Care Appeals Program are set forth at N.J.A.C. 11:24-8.8.

3. The Department shall establish a per case reimbursement schedule for all IUROs that participate in the Independent Health Care Appeals Program, based on the bids obtained by IUROs.

(b) Carriers who are the subject of an appeal through the Independent Health Care Appeals Program shall be responsible for paying the cost of the appeal.

1. The carrier shall be responsible to pay the per case cost that is applicable on the date that the preliminary review of the appeal is completed by the IURO.

2. The carrier shall submit payment to the IURO for the appeal no later than 30 days following the date that the IURO renders its determination on the appeal in writing to the Department.

N.J. Admin. Code § 11:24A-5.1

Amended by R.2005 d.418, effective 11/21/2005.
See: 37 N.J.R. 2174(a), 37 N.J.R. 4536(a).
In (a)1, rewrote "8-7" as "8.7"; in (b)2, substituted "determination on the appeal" for "final recommendation."