N.J. Admin. Code § 13:30-8.10

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

Section 13:30-8.10 - Third-party payor records

(a) No licensee shall submit any claim, bill or govern-mental assistance claim to a third party payor for dental services rendered to any patient which involves dishonesty, fraud, deception or misrepresentation.

(b) No licensee shall submit to a third-party payor any claim, bill, or governmental assistance claim that contains any of the following:

1. Any treatment date, which does not accurately reflect the date when the service and procedures were actually performed;

2. Any description of a dental service or procedure, which does not accurately reflect the actual work performed;

3. Any service or procedure, which cannot be justified by the licensee as necessary, proper, and/or beneficial;

4. Any statement or attachment material to the claim, which is known to be false or misleading; or

5. A charge for any service or procedure the amount of which has been advertised as free or complimentary or for an amount that exceeds the advertised charge for discounted services or procedures.

(c) A licensee who renders dental services or procedures to a patient enrolled in any dental plan with co-payment features and who intends to waive any part of the co-payment or all of the co-payment by the patient shall, when submitting any claim or bill to the third party payor, conspicuously disclose on the face of the claim or bill in a legible manner, or in the electronic claim submission, that the co-payment, or a portion of the co-payment, shall not be billed to, or collected from, the patient.

(d) The accuracy of all information contained in written or electronic submissions to a third-party payor including predeterminations, claims, bills, or governmental assistance claims, shall be the personal responsibility of the licensee whose name, license number, or signature appears on the signature line of the claim. In the case of electronic claims, the licensee identified as the provider shall be held responsible for the accuracy of the information whether or not the licensee actually completed the claim. The Board shall presume that the licensee identified on the claim reviewed its contents and approved its submission.

1. In the event that no licensee is identified on the claim, the patient's dentist of record as defined in N.J.A.C. 13:30-8.15 shall be the licensee responsible for the claim.

2. It shall not be a defense to an allegation of a violation of this section that the claim was completed or submitted by an agent of the licensee.

(e) All third-party payor records shall be maintained pursuant to the provisions of N.J.A.C. 13:30-8.7 or be readily retrievable.

N.J. Admin. Code § 13:30-8.10

New Rule, R.1981 d.175, eff. 6/4/1981.
See: 13 N.J.R. 102(c), 13 N.J.R. 366(a).
Amended by R.1985 d.196, effective 4/15/1985.
See: 17 N.J.R. 378(a), 17 N.J.R. 972(a).
Recodified from N.J.A.C. 13:30-8.12 by R.1990 d.205, effective 4/2/1990.
See: 22 N.J.R. 149(b), 22 N.J.R. 1145(a).
Amended by R.1990 d.311, effective 6/18/1990.
See: 21 N.J.R. 2226(a), 22 N.J.R. 153(a), 22 N.J.R. 1914(a).
New (d)-(f) added regarding signature of forms by treating dentist.
Amended by R.1995 d.191, effective 4/3/1995.
See: 27 N.J.R. 293(a), 27 N.J.R. 1424(b).
Amended by R.1998 d.90, effective 2/17/1998.
See: 29 N.J.R. 4069(b), 30 N.J.R. 686(a).
In (a), (b), and (d), substituted "claim" for "form"; added a new (b)4; in (c), added "or in the electronic claim submission"; rewrote (d); added (d)1 and 2; added a new (e); and deleted existing (e) and (f).
Amended by R.2000 d.147, effective 4/3/2000.
See: 32 N.J.R. 215(a), 32 N.J.R. 1221(a).
Rewrote (a); in (b), rewrote the introductory paragraph; and in (d), deleted ", but not limited to," following "including" in the first sentence.
Amended by R.2005 d.309, effective 9/19/2005.
See: 37 N.J.R. 1149(a), 37 N.J.R. 3709(a).
In (b), deleted "or" in 3, added "; or" and removed "." in 4, added 5.
Amended by R.2011 d.041, effective 2/7/2011.
See: 42 N.J.R. 2217(a), 43 N.J.R. 310(a).
In the introductory paragraph of (b), substituted "third-party" for "third party", deleted a comma following "bill" and inserted a comma following the second occurrence of "claim"; in (b)1 and (b)2, substituted "performed" for "completed"; and in (b)4, inserted "or attachment" and inserted a comma following "claim".

Amended by 53 N.J.R. 619(c), effective 4/19/2021