Reimbursement for covered services, conditions
See bold text below:
a. When a hospital or physician complies with the provisions set forth in section 5 of P.L. 2005, c. 352 (C. 17B:30-52), no payer, or payer’s agent, shall deny reimbursement to a hospital or physician for covered services rendered to a covered person on grounds of medical necessity in the absence of fraud or misrepresentation if the hospital or physician:
(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 physician within the time frames established pursuant to section 5 of P.L. 2005, c. 352 (C. 17B:30-52); 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 physician.
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, or payer’s agent, shall amend a claim by changing the diagnostic code assigned to the services rendered by a hospital or physician without providing written justification.