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:
a. received;
b. resolved;
c. resolved in favor of the carrier;
d. resolved against the carrier; and
e. compromised.
a. received;
b. resolved;
c. resolved in favor of the carrier;
d. resolved against the carrier; and
e. compromised.
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.