NJ Admin Code §11:22-1.10(a)(4)

October 15, 2021 5:32 am Published by

(4) The health carrier or its agent shall communicate the results of the internal review in a written decision to the provider, which shall include:

(i) The names, titles, and qualifying credentials of the person or persons participating in the internal review;

(ii) A statement of the provider’s grievance;

(iii) The decision of the reviewer(s), together with a detailed explanation of the basis for such decision;

(iv) A description of the substantiating documentation, which supports the decision;

(v) If the payment decision is adverse to the health care provider in any respect, a description of the method to obtain an external review of the decision by arbitration pursuant to 11:22-1.13; and

(vi) If the decision favors the health care provider in any respect, the health carrier or its agent shall be required to pay within 30 calendar days of the date of issuance of the health carrier’s or its agent’s determination of the internal appeal, the amount due as determined by the internal appeal, if applicable, with accrued interest at the rate of 12 percent per year calculated from the date of receipt of the internal appeal by the health carrier or its agent at its designated address.

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