New Jersey § 26:2ss-6

§ 26:2ss-6.

a. A carrier shall update the carrier's website within 20 days of the addition or

termination of a provider from the carrier's network or a change in a physician's

affiliation with a facility, provided that in the case of a change in affiliation

the carrier has had notice of such change. b. With respect to out-of-network services, for each health benefits plan offered,

a carrier shall, consistent with State and federal law, provide a covered person with: (1) a clear and understandable description of the plan's out-of-network health care

benefits, including the methodology used by the entity to determine the allowed amount

for out-of-network services; (2) the allowed amount the plan will reimburse under that methodology and, in situations

in which a covered person requests allowed amounts associated with a specific Current

Procedural Terminology code, the portion of the allowed amount the plan will reimburse

and the portion of the allowed amount that the covered person will pay, including

an explanation that the covered person will be required to pay the difference between

the allowed amount as defined by the carrier's plan and the charges billed by an out-of-network

provider; (3) examples of anticipated out-of-pocket costs for frequently billed out-of-network

services; (4) information in writing and through an internet website that reasonably permits

a covered person or prospective covered person to calculate the anticipated out-of-pocket

cost for out-of-network services in a geographical region or zip code based upon the

difference between the amount the carrier will reimburse for out-of-network services

and the usual and customary cost of out-of-network services; (5) information in response to a covered person's request, concerning whether a health

care provider is an in-network provider; (6) such other information as the commissioner determines appropriate and necessary

to ensure that a covered person receives sufficient information necessary to estimate

their out-of-pocket cost for an out-of-network service and make a well-informed health

care decision; and (7) access to a telephone hotline that shall be operated no less than 16 hours per

day for consumers to call with questions about network status and out-of-pocket costs. c. If a carrier authorizes a covered health care service to be performed by an in-network

health care provider with respect to any health benefits plan, and the provider or

facility status changes to out-of-network before the authorized service is performed,

the carrier shall notify the covered person that the provider or facility is no longer

in-network as soon as practicable. If the carrier fails to provide the notice at least 30 days prior to the authorized

service being performed, the covered person's financial responsibility shall be limited

to the financial responsibility the covered person would have incurred had the provider

been in-network with respect to the covered person's health benefits plan. d. A carrier shall incorporate into the Explanation of Benefits and all reimbursement

correspondence to the consumer and the provider clear and concise notification that

inadvertent and involuntary out-of-network charges are not subject to balance billing

above and beyond the financial responsibility incurred under the terms of the contract

for in-network service. Any attempt by the provider to collect, bill, or invoice funds should be promptly

reported to the carrier's customer service department at the phone number that the

carrier shall provide on the Explanation of Benefits and all reimbursement correspondence

to the consumer. e. A carrier, and any other entity providing or administering a self-funded health

benefits plan that elects to be subject to section 9 of this act, shall issue a health

insurance identification card to the primary insured under a health benefits plan. In a form and manner to be prescribed by the department, the card shall indicate

whether the plan is insured or, in the case of self-funded plans that elect to be

subject to section 9 of this act, 1 whether the plan is self-funded and whether the plan elected is to be subject to

this act. f. A carrier shall include in the carrier's annual public regulatory filings, and

in a manner to be determined by the Department of Banking and Insurance, the number

of claims submitted by health care providers to the carrier which are denied or down

coded by the carrier and the reason for the denial or down coding determination. 1

N.J.S.A. § 26:2SS-9.