17B:30-55.1. Short title.

2. This act shall be known and may be cited as 12 the “Ensuring Transparency in Prior Authorization Act.”

17B:30-55.2. Findings, declarations.

3. The Legislature finds and declares that:

a. Prior authorization is a type of utilization management technique used by health plans and carriers to ensure safety and appropriateness of medical and pharmacy services, reduce low-value care, and control costs;

b. Providers and patients have raised concerns that the current process of prior authorization is burdensome and leads to care being delayed or abandoned;

c. In 2005, New Jersey enacted the “Health Claims Authorization, Processing and Payment Act,” (“HCAPPA”), a groundbreaking law which established uniform procedures and guidelines for hospitals, physicians and health insurance carriers to follow in communicating and following utilization management decisions and determinations on behalf of patients;

d. In the nearly two decades since HCAPPA was signed into law, the process has continued to be a source of abrasion and concern for providers and patients;

e. The Centers for Medicare and Medicaid Services have recently implemented additional controls on the prior authorization, process such as accelerated turnaround times for prior authorization requests from providers, and are currently considering, among other items, ways to improve efficiency in prior authorization, including the use of electronic submission of prior authorization requests;

f. When it is used, prior authorization should utilize an automated process to minimize the burden placed upon both physicians and health plans; and

g. Therefore, because it is fair and reasonable for hospitals and physicians to receive reimbursement for health care services delivered to covered persons under their health benefits plans and inefficiencies in any area of the health care delivery system reflect poorly on all aspects of the health care delivery system, and because those inefficiencies can harm patients, it is appropriate for the
Legislature to update now the uniform procedures and guidelines for hospitals, physicians and health insurance carriers to follow in communicating and following utilization management decisions and
determinations on patients’ behalf.

17B:30-55.3 Definitions.

4. As used in sections 4 through 17 of P.L. , c. (C. ) (pending before the Legislature as this bill):

“Adverse determination” means a decision by a payer that the health care services furnished or proposed to be furnished to a covered person are not medically necessary, or are experimental or investigational; and benefit coverage is therefore denied, reduced, or terminated. A decision to deny, reduce, or terminate services which are not covered for reasons other than their medical necessity or
experimental or investigational nature is not an “adverse determination” for the purposes of P.L. , c. (C. ) (pending before the Legislature as this bill).

“Authorization” means a determination required under a health benefits plan, that based on the information provided, satisfies the requirements under the member’s health benefits plan for medical
necessity, and includes, but is not limited to, prior authorization.

“Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

U.R. Criteria

“Clinical criteria” means the written policies; written screening procedures; determination rules; determination abstracts; clinical protocols; practice guidelines; medical protocols; and any other criteria or rationale used for the purposes of utilization management to determine the necessity and appropriateness of covered services.

“Commissioner” means the Commissioner of Banking and Insurance.

“Covered person” means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

“Covered service” means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services, including, but not limited
to, health care procedures, treatments, or services and the provision of pharmaceutical products or services or durable medical equipment.

“Emergency health care services” means health care services that are provided in an emergency
facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be
expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in: (1) placing the health of the patient in jeopardy; (2) serious impairment to bodily function; or (3) serious dysfunction of any bodily organ or part.

“Generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant
medical community; physician and specialty society recommendations; and the views of physicians practicing in relevant clinical areas.

“Health benefits plan” means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a
carrier. For the purposes of sections 4 through 17 of 25 P.L. , c. (C. ) (pending before the Legislature as this bill), health benefits plan shall not include the following plans, policies, or contracts: accident only; credit; disability; long-term care; Medicare Supplement; Medicare Advantage; Medicaid
Civilian Health and Medical Program for the Uniformed Services; CHAMPUS supplement coverage; coverage arising out of a workers’ compensation or similar law; automobile medical payment
insurance; personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.); or hospital confinement indemnity coverage.

“Health care provider” means a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.

“Health care service” means health care procedures, treatments or services provided by: (1) a health care facility licensed in New Jersey; or (2) a doctor of medicine, a doctor of osteopathy, or a health care
provider performing within the scope of practice of the profession in which the provider is licensed in New Jersey. “Health care service” also includes the provision of pharmaceutical products or services or
durable medical equipment.

“Hospital” means a general acute care facility licensed by the Commissioner of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), including rehabilitation, psychiatric, and long-term acute
facilities.

Medical Necessity-Definition

“Medical necessity” or “medically necessary” means or describes a health care service that a health care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the covered person’s illness, injury, or disease; not primarily for the convenience of the covered person or the health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person’s illness, injury, or disease.

“NCPDP SCRIPT Standard” means the National Council for Prescription Drug Programs SCRIPT Standard Version 2017071, or the most recent standard adopted by the United States Department of
Health and Human Services (HHS). Subsequently released versions of the NCPDP SCRIPT Standard may be used.

“Network provider” means a participating hospital or physician under contract or other agreement with a carrier to furnish health care services to covered persons.

“Payer” means a carrier which requires that utilization management be performed to authorize the approval of a health care service and includes an organized delivery system that is certified by the Commissioner of Banking and Insurance or licensed by the commissioner pursuant to P.L.1999, c.409 (C.17:48H-1 et seq.) and shall include a payer’s agent.

“Payer’s agent” means an intermediary contracted or affiliated with the payer to provide authorization or prior authorization for service or perform administrative functions including, but not limited to, the
payment of claims or the receipt, processing, or transfer of claims or claim information.

“Prior authorization” means the process by which a payer determines the medical necessity of an otherwise covered service prior to the rendering of the service including, but not limited to,
preadmission review, pretreatment review, utilization review, and case management. “Prior authorization” also includes a payer’s requirement that a covered person or health care provider notify the carrier or payer prior to providing a health care service.

“Submission” means transmission of information by a health care provider or the authorized representative of a health care provider to a payer by any means (1) to which a network provider and health benefits plan have agreed to consider acceptable, or (2) by a readily accessible secure communications mechanism identified by a payer or its agent on its public website.

“Urgent care” means any claim for medical care or treatment with respect to which the application of the time periods for making non3 urgent care determination may seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function or, in the opinion of a physician with knowledge of the medical condition of the covered person, subjects the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. In determining if a claim involves urgent care, a payer shall apply the judgement of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the medical condition of the covered person determines that a claim involves urgent care, the claim shall be treated as an urgent care claim.

“Utilization management” means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to
recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the health benefits plan. The system may include, but shall not be limited to: preadmission certification; the application of practice guidelines; continued stay review; discharge planning; prior authorization of ambulatory care procedures; and retrospective review.

17B:30-55.4 Payer, information, utilization management, processing, payment of claims.

5. a. A payer shall provide the following information concerning utilization management and the processing and payment of claims in a clear and conspicuous manner, described in detail but also in easily understandable language, to covered persons, health care providers, and the general public, 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 the type 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;

(5) prescription drug formularies; and

(6) 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.

c. A payer shall, for health care services as defined pursuant to section 4 of P.L. , c. (C. ) (pending before the Legislature as this bill) but excluding the provision of pharmaceutical products:

(1) provide impacted contracted in-network health care providers with written notice of any new or materially adverse amended requirement or restriction no less than 90 days before the requirement
or restriction is implemented;

(2) ensure that any new or amended requirement is not implemented unless the payer’s Internet website has been updated to reflect the new or amended requirement or restriction; and

(3) withhold implementation of any new materially adverse requirement or restriction until and unless 90 days have passed since written notice was provided to an impacted contracted in network health care provider.

17B:30-55.5 Payer, respond, hospital, health care provider request, prior authorization.

6. A payer shall respond to a hospital or health care provider request for prior authorization of health care services by either approving or denying the request based on the covered person’s health benefits plan upon submission of all necessary information.

17B:30-55.6. Carrier, respond, prior authorization requests, medication coverage submitted, NCPDP SCRIPT Standard for ePA transactions.

State Medical Necessity Decisions-Deadlines

7.  a. A carrier shall respond to prior authorization requests for medication coverage submitted using the NCPDP SCRIPT Standard for ePA (electronic prior authorization) transactions, under the pharmacy benefit part of a health benefits plan, within 24 hours for urgent requests and 72 hours for nonurgent requests after obtaining all necessary information to make the approval or adverse determination.

b. Beginning January 1, 2027, a carrier shall only accept and respond to prior authorization requests for medication coverage, under the pharmacy benefit part of a health benefits plan submitted
through a secure electronic transmission using the NCPDP SCRIPT Standard for ePA transactions.

17B:30-55.7 Prior authorization, chronic, long-term care condition, validity, exception, timeline.

8. Except where shorter time frames are necessary to monitor patient safety or treatment effectiveness and with notice to the treating provider, if a payer requires prior authorization for a health care service for the treatment of a chronic or long-term care condition, the prior authorization shall remain valid for 180 days and the payer shall not require the covered person to obtain a prior authorization again for the health care service 45 within the 180-day period.

17B:30-55.8 Prior authorization, denial, limitation imposed by payer, physician, scope of actions.

9. Any denial of a request for prior authorization or limitation imposed by a payer on a requested service on the basis of utilization management determination shall be made by a physician
who shall:

(a) make the adverse determination under the clinical direction of a medical director of the payer who
shall:

(1) be licensed in this State; and

(2) strictly follow a medical policy that has been developed and made available in accordance with P.L. , c. (C. ) (pending before the Legislature as this bill) and the “New Jersey Health Care Quality Act,” P.L.1997, c.192 (C.26:2S-1 et seq.);

b.  not be compensated by a payer based on the approval or denial rate of the reviewing physician; and

c. not be provided preferential treatment by a payer in the requests for prior authorization of the reviewing physician if that physician is also a network provider for the payer.

17B:30-55.9 Prior authorization, defined number, discrete services, set time frame, validity, exception.

Retroactive Denial

10. Except where shorter time frames are necessary to monitor patient safety or treatment effectiveness and with notice to the treating provider, prior authorization for a service which
includes a defined number of discrete services within a set time frame shall be valid for purposes of authorizing the health care provider to provide care for a period of 180 days from the date the provider receives the prior authorization and a payer shall not revoke, limit, condition or restrict a prior authorization within that period if (1) the covered person continues to be eligible for coverage; (2) the clinical information provided at the time the prior authorization request was made has not been misrepresented by the treating physician or covered person; and (3) there has not been a material change in the clinical circumstances or condition of the covered person.

17B:30-55.10 Payer to honor prior authorization granted to covered person by previous payer, initial coverage, upon receipt of documentation.

11. a. On receipt of information documenting a prior authorization from the covered person or the health care provider of the covered person, a payer shall honor a prior authorization granted to a covered person by a previous payer for at least the initial 60 days of coverage under a new health plan of the covered person, if that prior authorization was based on information provided in good faith by a provider.

b. During the initial 60 days described in subsection a. of this section, a payer may perform its own review to grant a prior authorization.

c. If there is a change in coverage or approval criteria for a previously prior authorized covered service by the health benefits plan issuing the change, the change in coverage or approval criteria shall not affect a covered person who received prior authorization before the effective date of the change for the remainder of the plan year of the covered person, unless the prior authorization previously issued for a covered service was issued based on materially inaccurate medical information or fraudulent information.

d. A payer shall continue to honor a prior authorization it has granted to a covered person when the covered person changes products under the same payer, provided the service for which prior
authorization was issued remains a covered benefit under the terms and conditions of the replacement health benefits plan.

17B:30-55.11 Denial of prior authorization, communicated via written communication agreed to by payer, hospital, health care provider.

12.  a. A denial of prior authorization shall be communicated to the hospital or health care provider by facsimile, e-mail or any other means of written communication agreed to by the payer and hospital or health care provider, as follows:

State Medical Necessity Decisions-Deadlines

(1) in the case of a request for prior authorization for a covered person who will be receiving inpatient hospital services, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer, following the time the request was made;

(2) in the case of a request for prior authorization for a covered person who is currently receiving inpatient hospital services or care rendered in the emergency department of a hospital, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 24 hours;

(3) in the case of a request for prior authorization for a covered person who will be receiving health care services in an outpatient or other setting, including, but not limited to, a clinic, rehabilitation facility or nursing home, the payer shall communicate the denial of the request or the limitation imposed on the requested service to the hospital or health care provider within a time frame appropriate to the medical exigencies of the case but no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer, following the time the request was made;

(4) in the case of a claim involving urgent care, the payer shall notify the hospital or health care provider of the carrier’s benefit determination as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the carrier, unless the hospital or health care provider fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan. In the case of such a failure, the carrier shall notify the hospital or health care provider as soon as possible, but not later than 24 hours after receipt of the claim by the payer, of the specific information necessary to complete the claim. The hospital or health care provider shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The payer shall notify the hospital or health care provider of the carrier’s benefit determination as soon as possible, but in no case later than 48 hours after the carrier’s receipt of the specified information; and

(5) if the payer requires additional information to approve or make an adverse determination with regard to a request for prior authorization, the payer shall so notify the hospital or health care
provider by facsimile, e-mail or any other means of written communication agreed to by the payer and hospital or health care provider within the applicable time frame set forth in paragraph (1),
(2) or (3) of this subsection and shall identify the specific information needed to approve or make the adverse determination with regard to the request for authorization.

b. If the payer is unable to approve or make an adverse determination with regard to a request for authorization within the applicable time frame set forth in paragraph (1), (2), (3) or (4) of this subsection because of the need for this additional information, the payer shall have an additional period within which to approve or make an adverse determination with regard to the request,
as follows:

(1) in the case of a request for prior or concurrent authorization for a covered person who will be receiving inpatient hospital services, within a time frame appropriate to the medical exigencies of the case but no later than 12 calendar days beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or made an adverse determination with regard to the request for authorization. For requests made through an electronic portal provided by the payer, this time frame shall be within nine calendar days;

(2) in the case of a request for prior or concurrent authorization for a covered person who is currently receiving inpatient hospital services or care rendered in the emergency department of a hospital, no more than 24 hours beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or make an adverse determination with regard to the request for prior or concurrent authorization; and

(3) in the case of a request for prior or concurrent authorization for a covered person who will be receiving health care services in another setting, within a time frame appropriate to the medical exigencies of the case but no more than 12 calendar days beyond the time of receipt by the payer from the hospital or health care provider of the additional information that the payer has identified as needed to approve or make an adverse determination with regard to the request for authorization.
For requests made through an electronic portal provided by the payer, this time frame shall be within nine calendar days.

c. Payers and hospitals shall have appropriate staff available between the hours of 9 a.m. and 5 p.m., seven days a week, to respond to authorization requests within the time frames established pursuant
to subsection a. of this section.

d. If a payer fails to respond to an authorization request within the time frames established pursuant to subsection a. or b. of this section, the hospital or health care provider’s claim for the service shall not be denied on the basis of a failure to secure prior or concurrent authorization for the service.

e. If a hospital or health care provider fails to respond to a payer’s request for additional information necessary to render an authorization decision within 72 hours, the hospital or health care provider’s request for authorization shall be deemed withdrawn.

17B:30-55.12 Adverse determinations, appeal, reviewed by physician.

13. A payer shall ensure that any adverse determinations of any appeal are reviewed by a physician. The physician shall: be board certified in a same or similar specialty that has experience treating the condition or service under review or has experience treating the condition within the last five years;

b. not be paid by a payer based on the reviewing physician’s denial or approval rate;

c. not have been directly involved in making an initial adverse determination for the same claim;

d. consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the payer by the health care provider of
the covered person, any relevant records provided to the payer by a health care facility, and any medical literature provided to the payer by the health care service provider of the covered person;

e. not be provided preferential treatment by the payer in the reviewing physician’s own requests for prior authorization if the reviewing physician is also a network provider; and

f. when requested by the treating provider, engage in a telephonic conversation with the treating provider to discuss the need for the prescribed medication or service.

17B:30-55.13 Payer shall not deny reimbursement, hospital, health care provider in compliance, circumstances.

Retroactive Denial

14. a. When a hospital or health care provider complies with the provisions set forth in P.L. , c. (C. ) (pending before the Legislature as this bill), no payer shall deny reimbursement to a hospital or health care provider for covered services rendered to a covered person on grounds of failure to secure prior or concurrent authorization in the absence of fraud or misrepresentation if the hospital or health care provider:

(1) requested authorization from the payer and received approval for the health care services delivered prior to rendering the service;

(2) requested authorization from the payer for the health care services prior to rendering the services and the payer failed to respond to the hospital or health care provider within the time frames established pursuant to P.L. , c. (C. ) (pending before this Legislature as this bill); or

(3) received authorization for the covered service for a patient who is no longer eligible to receive coverage from that payer and it is determined that the patient is covered by another payer, in which case the subsequent payer, based on the subsequent payer’s benefits plan, shall accept the authorization and reimburse the hospital or health care provider.

b. If the hospital is a network provider of the payer, health care services shall be reimbursed at the contracted rate for the services provided.

c. No payer shall amend a claim by changing the diagnostic code assigned to the services rendered by a hospital or health care provider without providing written justification.

17B:30-55.14 Payer, reimbursement according to provider contract, medically necessary emergency, urgent care covered under plan.

15. a. A payer shall reimburse a hospital or health care provider according to the provider contract for all medically necessary emergency and urgent care health care services that are covered under the health benefits plan, including all tests necessary to determine the nature of an illness or injury; pre-hospital transportation; or the provision of emergency health care services.

b. A payer shall allow a covered person and the covered person’s health care provider a minimum of 24 hours following an emergency admission or provision of emergency health care services for the
covered person or health care provider to notify the payer of the admission or provision of covered services. If the admission or covered service occurs on a holiday or weekend, a payer shall not
require notification until the next business day after the admission or provision of the covered service.

c. A payer shall approve coverage for emergency health care services necessary to screen and stabilize a covered person without requiring any prior authorization. Admission on an in-patient basis may be subject to concurrent review.

d. A payer shall not determine medical necessity or appropriateness of emergency health care services based on whether or not those services are provided by participating or nonparticipating providers. A payer shall ensure that restrictions on coverage of emergency health care services provided by nonparticipating providers shall not be greater than restrictions that apply when those services are
provided by participating providers.

State Medical Necessity Decisions-Deadlines

e. If a covered person receives an emergency health care service that requires immediate post-evaluation or post-stabilization services, a payer shall make an authorization determination within 150 minutes of receiving a request. If the authorization determination is not made within 150 minutes, those services shall be deemed approved.

17B:30-55.15 Failure by payer to comply with deadline, health care services subject to review, automatic authorization.

16. a. In addition to the protections afforded to a 34 health care provider or patient by the requirements of P.L. , c. (C. ) (pending before the Legislature as this bill), any failure by a payer to comply with a deadline shall result in any health care services subject to review being automatically deemed authorized.

b. Notwithstanding any health care services being automatically deemed authorized pursuant to the terms of P.L. , c. (C. ) (pending before the Legislature as this bill), the Commissioner of Banking and Insurance shall enforce the provisions of sections 3 through 15 of P.L. , c. (C. ) (pending before the Legislature as 46 this bill) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 47 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L. , c. (C. ) (pending before the Legislature as this bill). A payer found in violation of those sections shall be liable for a civil penalty of not more than $10,000 for each day that the payer is in violation if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the payer has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with the “Penalty Enforcement Law of 1999,” P.L.1999, c.274 (C.2A:58-10 et seq.). The commissioner’s determination shall be a final agency decision subject to review by the Appellate Division of the Superior Court.

c. If the Commissioner of Banking and Insurance has reason to believe that a person is engaging in a practice or activity, for the purpose of avoiding or circumventing the legislative intent of sections
18 4 through 17 of P.L. , c. (C. ) (pending before the Legislature as this bill) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L. , c. (C. ) (pending before the Legislature as this bill), the Commissioner of Banking and Insurance is authorized to promulgate rules or regulations necessary to prohibit that practice or activity and levy a civil penalty of not more than $10,000 for each day that person is in violation of that rule or regulation.

d. For the purpose of administering the provisions of sections 3 through 15 of P.L. , c. (C. ) (pending before the Legislature as this bill) and sections 2, 3, 4, 5, 6, 7 and 10 of P.L.1999, c.154 (C.17:48-8.4, 17:48A-7.12, 17:48E-10.1, 17B:26-9.1, 17B:27-44.2, 26:2J-8.1 and 17:48F-13.1) as amended by P.L. , c. (C. ) (pending before the Legislature as this bill), 50 percent of the penalty monies collected pursuant to subsections b. and c. of this section shall be deposited into the General Fund. For the purpose of providing payments to hospitals in accordance with the formula used for the distribution of charity care subsidies that are provided pursuant to P.L.1992, c.160 (C.26:2H-18.51 et seq.), 50 percent of the penalty monies collected pursuant to subsections b. and c. of this section shall be deposited into the Health Care Subsidy Fund established pursuant to section 8 of P.L.1992, c.160 (C.26:2H-18.58).

e. A penalty levied pursuant to this section against a payer that does not reserve the right to change the premium shall be credited towards a penalty levied against the payer by the Department of Human Services for the same violation.

17B:30-55.16 Statistics available regarding prior authorization approvals, denials, website.

17. A payer shall make statistics available regarding prior authorization approvals and denials on its Internet website in a readily accessible format, as determined by the commissioner.  Payers shall include categories for:

a. health care provider specialty;

b. medication or diagnostic tests and procedures;

c. indication offered;

d. reason for denial;

e. whether prior authorization determinations were:

(1) appealed; or

(2) approved or denied on appeal;

f. the time between submission of prior authorization requests and the determination;

g. the average median time elapsed between a request for clinical records from the requesting health care provider and receipt of adequate clinical records to complete the prior authorization; and

h. the number of appeals generated for cases denied in which there was inadequate or no prior clinical information.

17B:30-55.17 Liberal construction.

27.   P.L.2023, c.296 (C.17B:30-55.1 et al.) shall be liberally construed to effectuate the legislative purposes thereof.

17B:30-56 Rules, regulations.

20.   The Commissioner of Banking and Insurance shall promulgate rules and regulations pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to carry out the purposes of P.L.2023, c.296 (C.17B:30-55.1 et al.).

One can see the text of this section as it existed in 2023 at  https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu.

This section was amended by A 1255 (2024).  It appears that as of the date of this entry, those amendment are not yet included in the New Jersey online statutes.  But one can access A 1255 (2024) at  https://www.njleg.state.nj.us/bill-search/2022/A1255.