New Jersey § 26:2j-8

§ 26:2j-8.

a. Within 180 days of the adoption of a timetable for implementation pursuant to section

1 of P.L.1999, c. 154 ( C.17B:30-23 ), a health maintenance organization or its agent or a subsidiary that processes health care benefits claims as a third party administrator,

shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance

that it will adopt and implement all of the standards to receive and transmit health

care transactions electronically, according to the corresponding timetable, and otherwise

comply with the provisions of this section, as a condition of its continued authorization

to do business in this State. The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation

requirement when it has been demonstrated to the commissioner's satisfaction that

compliance with the timetable for implementation will result in an undue hardship

to a health maintenance organization , or its agent , its subsidiary or its covered persons. b. Within 12 months of the adoption of regulations establishing standard health care

enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to

section 1 of P.L.1999, c. 154 ( C.17B:30-23 ), a health maintenance organization or its agent or a subsidiary that processes health care benefits claims as a third party administrator

shall use the standard health care enrollment and claim forms in connection with all

group and individual health maintenance organization coverage for health care services

issued, delivered, executed or renewed in this State. c. Twelve months after the adoption of regulations establishing standard health care

enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to

section 1 of P.L.1999, c. 154 ( C.17B:30-23 ), a health maintenance organization or its agent shall require that health care providers file all claims for payment for health care

services. A covered person who receives health care services shall not be required to submit

a claim for payment, but notwithstanding the provisions of this subsection to the

contrary, a covered person shall be permitted to submit a claim on his own behalf,

at the covered person's option. All claims shall be filed using the standard health care claim form applicable to

the contract. d. For the purposes of this subsection, “ substantiating documentation ” means any information specific to the particular health care service provided to

a covered person. (1) Effective 180 days after the effective date of P.L.1999, c. 154, a health maintenance organization or its agent, hereinafter the payer, shall remit

payment for every insured claim submitted by a covered person or health care provider , no later than the 30th calendar day following receipt of the claim by the payer

or no later than the time limit established for the payment of claims in the Medicare

program pursuant to 42 U.S.C. s.1395u(c)(2)(B) , whichever is earlier, if the claim is submitted by electronic means, and no later

than the 40th calendar day following receipt if the claim is submitted by other than

electronic means, if: (a) the health care provider is eligible at the date of service; (b) the person who received the health care service was covered on the date of service; (c) the claim is for a service or supply covered under the health benefits plan; (d) the claim is submitted with all the information requested by the payer on the

claim form or in other instructions that were distributed in advance to the health

care provider or covered person in accordance with the provisions of section 4 of P.L.2005, c. 352 ( C.17B:30-51 ); and (e) the payer has no reason to believe that the claim has been submitted fraudulently . (2) If all or a portion of the claim is not paid within the time frames provided in paragraph (1) of this subsection because: (a) the claim submission is incomplete because the required substantiating documentation

has not been submitted to the payer; (b) the diagnosis coding, procedure coding, or any other required information to be submitted

with the claim is incorrect; (c) the payer disputes the amount claimed; or (d) there is strong evidence of fraud by the provider and the payer has initiated

an investigation into the suspected fraud , the payer shall notify the health care provider , by electronic means and the covered person in writing within 30 days of receiving an electronic claim, or notify the covered person and health care provider

in writing within 40 days of receiving a claim submitted by other than electronic

means, that: (i) the claim is incomplete with a statement as to what substantiating documentation

is required for adjudication of the claim; (ii) the claim contains incorrect information with a statement as to what information

must be corrected for adjudication of the claim; (iii) the payer disputes the amount claimed in whole or in part with a statement as

to the basis of that dispute; or (iv) the payer finds there is strong evidence of fraud and has initiated an investigation

into the suspected fraud in accordance with its fraud prevention plan established

pursuant to section 1 of P.L.1993, c. 362 ( C.17:33A-15 ), or referred the claim, together with supporting documentation, to the Office of

the Insurance Fraud Prosecutor in the Department of Law and Public Safety established

pursuant to section 32 of P.L.1998, c. 21 ( C.17:33A-16 ) . (3) If all or a portion of an electronically submitted claim cannot be adjudicated because

the diagnosis coding, procedure coding or any other data required to be submitted

with the claim was missing, the payer shall electronically notify the health care

provider or its agent within seven days of that determination and request any information

required to complete adjudication of the claim. (4) Any portion of a claim that meets the criteria established in paragraph (1) of this

subsection shall be paid by the payer in accordance with the time limit established

in paragraph (1) of this subsection. (5) A payer shall acknowledge receipt of a claim submitted by electronic means from a

health care provider , no later than two working days following receipt of the transmission of the claim. (6) If a payer subject to the provisions of P.L.1983, c. 320 ( C.17:33A-1 et seq. ) has reason to believe that a claim has been submitted fraudulently, it shall investigate

the claim in accordance with its fraud prevention plan established pursuant to section

1 of P.L.1993, c. 362 ( C.17:33A-15 ), or refer the claim, together with supporting documentation, to the Office of the

Insurance Fraud Prosecutor in the Department of Law and Public Safety established

pursuant to section 32 of P.L.1998, c. 21 ( C.17:33A-16 ). (7) Payment of an eligible claim pursuant to paragraphs (1) and (4) of this subsection shall be deemed to be overdue if not remitted to the claimant

or his agent by the payer on or before the 30th calendar day or the time limit established

by the Medicare program, whichever is earlier, following receipt by the payer of a

claim submitted by electronic means and on or before the 40th calendar day following

receipt of a claim submitted by other than electronic means. If payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of paragraph (2) or paragraph (3) of this subsection, the claims payment shall be overdue if not remitted to the claimant

or his agent by the payer on or before the 30th calendar day or the time limit established

by the Medicare program, whichever is earlier, for claims submitted by electronic

means and the 40th calendar day for claims submitted by other than electronic means,

following receipt by the payer of the required documentation or information or modification of an initial submission. If payment is withheld on all or a portion of a claim by a payer pursuant to paragraph

(2) or (3) of this subsection and the provider is not notified within the time frames

provided for in those paragraphs, the claim shall be deemed to be overdue. (8) (a) No payer that has reserved the right to change the premium shall deny payment

on all or a portion of a claim because the payer requests documentation or information

that is not specific to the health care service provided to the covered person. (b) No payer shall deny payment on all or a portion of a claim while seeking coordination

of benefits information unless good cause exists for the payer to believe that other

insurance is available to the covered person. Good cause shall exist only if the payer's records indicate that other coverage

exists. Routine requests to determine whether coordination of benefits exists shall not

be considered good cause. (c) In the event payment is withheld on all or a portion of a claim by a payer pursuant

to subparagraph (a) or (b) of this paragraph, the claims payment shall be deemed to

be overdue if not remitted to the claimant or his agent by the payer on or before

the 30th calendar day or the time limit established by the Medicare program, whichever

is earlier, following receipt by the payer of a claim submitted by electronic means

or on or before the 40th calendar day following receipt of a claim submitted by other

than electronic means. (9) An overdue payment shall bear simple interest at the rate of 12% per annum. The interest shall be paid to the health care provider at the time the overdue payment

is made. The amount of interest paid to a health care provider for an overdue claim shall

be credited to any civil penalty for late payment of the claim levied by the Department

of Human Services against a payer that does not reserve the right to change the premium. (10) With the exception of claims that were submitted fraudulently or submitted by

health care providers that have a pattern of inappropriate billing or claims that

were subject to coordination of benefits, no payer shall seek reimbursement for overpayment

of a claim previously paid pursuant to this section later than 18 months after the

date the first payment on the claim was made. No payer shall seek more than one reimbursement for overpayment of a particular

claim. At the time the reimbursement request is submitted to the health care provider,

the payer shall provide written documentation that identifies the error made by the

payer in the processing or payment of the claim that justifies the reimbursement request. No payer shall base a reimbursement request for a particular claim on extrapolation

of other claims, except under the following circumstances: (a) in judicial or quasi-judicial proceedings, including arbitration; (b) in administrative proceedings; (c) in which relevant records required to be maintained by the health care provider

have been improperly altered or reconstructed, or a material number of the relevant

records are otherwise unavailable; or (d) in which there is clear evidence of fraud by the health care provider and the

payer has investigated the claim in accordance with its fraud prevention plan established

pursuant to section 1 of P.L.1993, c. 362 ( C.17:33A-15 ), and referred the claim, together with supporting documentation, to the Office of

the Insurance Fraud Prosecutor in the Department of Law and Public Safety established

pursuant to section 32 of P.L.1998, c. 21 ( C.17:33A-16 ). (11) (a) In seeking reimbursement for the overpayment from the health care provider,

except as provided for in subparagraph (b) of this paragraph, no payer shall collect

or attempt to collect: (i) the funds for the reimbursement on or before the 45th calendar day following the

submission of the reimbursement request to the health care provider; (ii) the funds for the reimbursement if the health care provider disputes the request

and initiates an appeal on or before the 45th calendar day following the submission

of the reimbursement request to the health care provider and until the health care

provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e.

of this section are exhausted; or (iii) a monetary penalty against the reimbursement request, including but not limited

to, an interest charge or a late fee. The payer may collect the funds for the reimbursement request by assessing them against

payment of any future claims submitted by the health care provider after the 45th

calendar day following the submission of the reimbursement request to the health care

provider or after the health care provider's rights to appeal set forth under paragraphs

(1) and (2) of subsection e. of this section have been exhausted if the payer submits

an explanation in writing to the provider in sufficient detail so that the provider

can reconcile each covered person's bill. (b) If a payer has determined that the overpayment to the health care provider is

a result of fraud committed by the health care provider and the payer has conducted

its investigation and reported the fraud to the Office of the Insurance Fraud Prosecutor

as required by law, the payer may collect an overpayment by assessing it against payment

of any future claim submitted by the health care provider. (12) No health care provider shall seek reimbursement from a payer or covered person

for underpayment of a claim submitted pursuant to this section later than 18 months

from the date the first payment on the claim was made, except if the claim is the

subject of an appeal submitted pursuant to subsection e. of this section or the claim

is subject to continual claims submission. No health care provider shall seek more than one reimbursement for underpayment

of a particular claim. e. (1) A health maintenance organization or its agent, hereinafter the payer, shall establish

an internal appeal mechanism to resolve any dispute raised by a health care provider

regardless of whether the health care provider is under contract with the payer regarding

compliance with the requirements of this section or compliance with the requirements

of sections 4 through 7 of P.L.2005, c. 352 ( C.17B:30-51 through C.17B:30-54 ). No dispute pertaining to medical necessity which is eligible to be submitted to

the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c. 192 ( C.26:2S-11 ) shall be the subject of an appeal pursuant to this subsection. The payer shall conduct the appeal at no cost to the health care provider. A health care provider may initiate an appeal on or before the 90th calendar day following

receipt by the health care provider of the payer's claims determination, which is

the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance

which shall describe the type of substantiating documentation that must be submitted

with the form. The payer shall conduct a review of the appeal and notify the health care provider

of its determination on or before the 30th calendar day following the receipt of the

appeal form. If the health care provider is not notified of the payer's determination of the

appeal within 30 days, the health care provider may refer the dispute to arbitration

as provided by paragraph (2) of this subsection. If the payer issues a determination in favor of the health care provider, the payer

shall comply with the provisions of this section and pay the amount of money in dispute,

if applicable, with accrued interest at the rate of 12% per annum, on or before the

30th calendar day following the notification of the payer's determination on the appeal. Interest shall begin to accrue on the day the appeal was received by the payer. If the payer issues a determination against the health care provider, the payer shall

notify the health care provider of its findings on or before the 30th calendar day

following the receipt of the appeal form and shall include in the notification written

instructions for referring the dispute to arbitration as provided by paragraph (2)

of this subsection. The payer shall report annually to the Commissioner of Banking and Insurance the number

of appeals it has received and the resolution of each appeal. (2) Any dispute regarding the determination of an internal appeal conducted pursuant

to paragraph (1) of this subsection may be referred to arbitration as provided in

this paragraph. The Commissioner of Banking and Insurance shall contract with a nationally recognized,

independent organization that specializes in arbitration to conduct the arbitration

proceedings. Any party may initiate an arbitration proceeding on or before the 90th calendar day

following the receipt of the determination which is the basis of the appeal, on a

form prescribed by the Commissioner of Banking and Insurance. No dispute shall be accepted for arbitration unless the payment amount in dispute

is $1,000 or more, except that a health care provider may aggregate his own disputed

claim amounts for the purposes of meeting the threshold requirements of this subsection. No dispute pertaining to medical necessity which is eligible to be submitted to

the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c. 192 ( C.26:2S-11 ) shall be the subject of arbitration pursuant to this subsection. (3) The arbitrator shall conduct the arbitration proceedings pursuant to the rules

of the arbitration entity, including rules of discovery subject to confidentiality

requirements established by State or federal law. (4) An arbitrator's determination shall be: (a) signed by the arbitrator; (b) issued in writing, in a form prescribed by the Commissioner of Banking and Insurance,

including a statement of the issues in dispute and the findings and conclusions on

which the determination is based; and (c) issued on or before the 30th calendar day following the receipt of the required

documentation. The arbitration shall be nonappealable and binding on all parties to the dispute. (5) If the arbitrator determines that a payer has withheld or denied payment in violation

of the provisions of this section, the arbitrator shall order the payer to make payment

of the claim, together with accrued interest, on or before the 10th business day following

the issuance of the determination. If the arbitrator determines that a payer has withheld or denied payment on the

basis of information submitted by the health care provider and the payer requested,

but did not receive, this information from the health care provider when the claim

was initially processed pursuant to subsection d. of this section or reviewed under

internal appeal pursuant to paragraph (1) of this subsection, the payer shall not

be required to pay any accrued interest. (6) If the arbitrator determines that a health care provider has engaged in a pattern

and practice of improper billing and a refund is due to the payer, the arbitrator

may award the payer a refund, including interest accrued at the rate of 12% per annum. Interest shall begin to accrue on the day the appeal was received by the payer for

resolution through the internal appeals process established pursuant to paragraph

(1) of this subsection. (7) The arbitrator shall file a copy of each determination with and in the form prescribed

by the Commissioner of Banking and Insurance. f. As used in this section , “ insured claim ” or “ claim ” means a claim by a covered person for payment of benefits under an insured health maintenance organization contract

for which the financial obligation for the payment of a claim under the health maintenance

organization coverage for health care services rests upon the health maintenance organization. g. Any person found in violation of this section with a pattern and practice as determined

by the Commissioner of Banking and Insurance shall be liable to a civil penalty as

set forth in section 17 of P.L.2005, c. 352 ( C.17B:30-55 ).