ORDER NO.: A01-124

STATE OF NEW JERSEY
DEPARTMENT OF BANKING AND INSURANCE

IN THE MATTER OF COMPLIANCE WITH )
THE HEALTH BENEFIT PLANS - PROMPT ) ORDER
PAY RULES N.J.A.C. 11:22-1 )


This matter having been opened by the Commissioner of Banking and Insurance ("Commissioner") pursuant to the authority of N.J.S.A. 17:1-8.1, 17:1-15e, 17B:30-13.1, and 17B:30-23 et seq. and all powers expressed and implied therein; and

IT APPEARING that pursuant to N.J.S.A. 17B:30-23 et seq. the Commissioner has adopted the Health Benefit Plans – Prompt Pay Rules N.J.A.C. 11:22 and 11:2 effective January 2, 2001; and

IT FURTHER APPEARING that N.J.A.C. 11:22-1.8(a) requires every carrier (defined as an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, dental service corporation or dental plan organization) to establish an internal appeals mechanism to resolve disputes between carriers or their agents and participating health care providers relating to payment of claims but not including appeals made pursuant to N.J.A.C. 8:38-8.5 through 8.7 and N.J.A.C. 8:38A-3.6 through 3.7; and

IT FURTHER APPEARING that N.J.A.C. 11:22-1.8(b) requires carriers to offer an independent, external alternative dispute resolution mechanism to participating health care providers to review adverse decisions of its internal appeals process; and

IT FURTHER APPEARING that some carriers may not have established the internal and external appeal mechanisms required by N.J.A.C. 11:22-1.8(a) and (b).

THEREFORE, IT IS on this 9th day of May, 2001

ORDERED that any insurance company, health service corporation, medical service corporation, hospital service corporation, health maintenance organization, dental service corporation and dental plan organization that issues health benefit plans or dental plans in this State and that has participating healthcare providers:

  1. Shall submit a completed survey (Appendix) to:
  2. New Jersey Department of Banking and Insurance
    Division of Enforcement and Consumer Protection
    Attention: Prompt Pay Surveys
    20 West State Street
    P.O. Box 329
    Trenton, NJ 08625-0329

  3. Describe in detail the ADR ("Alternate Dispute Resolution") process that is being offered to participating health care providers to comply with N.J.A.C. 11:22-1.8(b), including identification of the independent party that is conducting the carrier’s external ADR process.
  4. Provide a copy of the instructions the carrier supplies to its participating health care providers on how to file an internal and external appeal. Explain how these instructions have been distributed, including the dates and manner of the distribution.
  5. Specify on the Appendix chart the number and the aggregate dollar amount of internal appeals of participating health care providers as of April 1, 2001, that have been:
  6. a. received;

    b. resolved;

    c. resolved in favor of the carrier;

    d. resolved against the carrier; and

    e. compromised.

  7. Specify in the Appendix chart the number and the aggregate dollar amount of external appeals of participating health care providers as of April 1, 2001, that have been:

    a. received;

    b. resolved;

    c. resolved in favor of the carrier;

    d. resolved against the carrier; and

    e. compromised.

  8. Verify that you submitted amendments to provider contracts or new provider contracts to the Department of Health and Senior Services ("DOHSS") and/or the Department of Banking and Insurance as applicable, to comply with N.J.A.C. 11:22-1.8(a) and 1.8(b)2. If amendments were not submitted, explain why such amendments or new contracts have not been submitted.

    The attached survey shall be completed and received by the Department no later than July 2, 2001. Failure to comply with the terms of this Order shall result in the imposition of penalties as authorized by law.

/s/ Karen L. Suter, Commissioner


Appendix/Survey