State Law

New Jersey Statutes-Title 17B. Insurance

08/19/2023 New Jersey Section 17B:30-51

Information required from payer

Payment Edits

a. A payer shall provide the following information concerning utilization management and the processing and payment of claims in a clear and conspicuous manner through an Internet website no later than 30 calendar days before the information or policies or any changes in the information or policies take effect:

(1)   a description of the source of all commercially produced clinical criteria guidelines and a copy of all internally produced clinical criteria guidelines used by the payer or its agent to determine the medical necessity of health care services;

(2)   a list of the material, documents or other information required to be submitted to the payer with a claim for payment for health care services;

(3)   a description of claims for which the submission of additional documentation or information is required for the adjudication of a claim fitting that description;

(4)   the payer’s policy or procedure for reducing the payment for a duplicate or subsequent service provided by a health care provider on the same date of service; and

(5)   any other information the commissioner deems necessary.

b.   Any changes in the information or policies required to be provided pursuant to subsection a. of this section shall be clearly noted on the Internet website.