Rutgers Law

New Jersey Statutes, Title: 17B, INSURANCE

    Chapter 30: Declaration of purpose

      Section: 17B:30-55.12: Adverse determinations, appeal, reviewed by physician.

          13. A payer shall ensure that any adverse determinations of any appeal are reviewed by a physician. The physician shall:

a. be board-certified in a same or similar specialty that has experience treating the condition or service under review or has experience treating the condition within the last five years;

b. not be paid by a payer based on the reviewing physician's denial or approval rate;

c. not have been directly involved in making an initial adverse determination for the same claim;

d. consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the payer by the health care provider of the covered person, any relevant records provided to the payer by a health care facility, and any medical literature provided to the payer by the health care service provider of the covered person;

e. not be provided preferential treatment by the payer in the reviewing physician's own requests for prior authorization if the reviewing physician is also a network provider; and

f. when requested by the treating provider, engage in a telephonic conversation with the treating provider to discuss the need for the prescribed medication or service.

L.2023, c.296, s.13.

This section added to the Rutgers Database: 2024-06-14 13:51:06.

Older versions of 17B:30-55.12 (if available):

Court decisions that cite this statute: CLICK HERE.