New Jersey § 26:2s-6

§ 26:2s-6.

a. A carrier which offers a managed care plan or uses a utilization management system

in any of its health benefits plans shall designate a licensed physician to serve

as medical director. The medical director, or his designee, shall be designated to serve as the medical

director for medical services provided to covered persons in the State and shall be

licensed to practice medicine in New Jersey. The medical director shall be responsible for treatment policies, protocols, quality

assurance activities and utilization management decisions of the carrier. The treatment policies, protocols, quality assurance program and utilization management

decisions of the carrier shall be based on generally accepted standards of health

care practice. The quality assurance and utilization management programs shall be in accordance

with standards adopted by regulation of the department pursuant to this act. b. The medical director shall ensure that: (1) Any utilization management decision to deny, reduce or terminate a health care

benefit or to deny payment for a health care service, because that service is not

medically necessary, shall be made by a physician. In the case of a health care service prescribed or provided by a dentist, the decision

shall be made by a dentist; (2) A utilization management decision shall not retrospectively deny coverage for

health care services provided to a covered person when prior approval has been obtained

from the carrier for those services, unless the approval was based upon fraudulent

information submitted by the covered person or the participating provider; (3) In the case of a managed care plan, a procedure is implemented whereby participating

physicians and dentists have an opportunity to review and comment on all medical and

surgical and dental protocols, respectively, of the carrier; (4) The utilization management program is available on a 24-hour basis to respond

to authorization requests for emergency and urgent services and is available, at a

minimum, during normal working hours for inquiries and authorization requests for

nonurgent health care services; and (5) In the case of a managed care plan, a covered person is permitted to: choose

or change a primary care physician from among participating providers in the provider

network, and, when appropriate, choose a specialist from among participating network

providers following an authorized referral, if required by the carrier, and subject

to the ability of the specialist to accept new patients.