Hearings for provider terminations
(a) A health care professional shall have the right to request a hearing in writing with respect to termination of the health care professional from a carrier’s network within 10 business days following the date of the notice.
1. A contract shall be deemed to have terminated, creating the right to a hearing, whenever a contract terminates on any date other than a designated renewal or anniversary date of the contract, except that no such right shall exist with respect to terminations described at N.J.A.C. 11:24A-4.8(b).2. If no renewal or anniversary date is specified in the contract, then the renewal or anniversary date shall be deemed to be the month and day in each calendar year on which the contract was originally signed by both parties, or became effective, whichever date is latest.
(b) The carrier shall hold a hearing within 30 days following receipt of a written request for a hearing by a terminated health care professional before a panel appointed by the carrier.
1. The panel shall consist of no less than three people.
2. At least one person on the panel shall be a clinical peer in the same or substantially similar discipline and specialty as the provider requesting the hearing.
3. The carrier shall not preclude the provider from being present at the hearing, nor shall the carrier preclude the provider from being represented by counsel at the hearing.
(c) The panel shall render a decision on the matter in writing within 30 days of the close of the hearing unless the panel provides notice of a need for an extension for rendering its decision, and provides the notice to both the carrier and the health care professional prior to the date the panel’s decision would otherwise be due.
1. The panel’s decision shall set forth the relevant contract provisions and the facts upon which the carrier and the provider have relied at the hearing.2. The panel shall recommend that the provider be terminated, reinstated or provisionally reinstated.
3. The panel shall specify its reasons for its recommendations, including the reasons for any conditions for provisional reinstatement.
4. The panel shall specify the conditions for provisional reinstatement, the duration of the conditions, and the consequences of a failure to meet the conditions.
5. In the event of reinstatement or provisional reinstatement, the panel shall specify the impact of the reinstatement upon the terms of duration of the contract at issue.
(d) In the event that the panel recommends that the health care professional be terminated, the carrier shall then provide notice of the termination to covered persons in accordance with N.J.A.C. 11:24A-4.8(c), as necessary.
See https://regulations.justia.com/states/new-jersey/title-11/chapter-24a/subchapter-4/