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Managed Care Provider Rights and Responsibilities
The New Jersey Health Care Quality Act (HCQA), N.J.S.A. 26:2S-1 et seq. and rules establish certain rights AND responsibilities for health care providers that contract with carriers for business that is subject to the HCQA. Whether your contract with a carrier is subject to the terms of the HCQA depends upon whether the business for which you are to deliver health care services is subject to the HCQA.
Your Rights
The following rights apply to all health care providers:
1. The right to have your application to participate in the carrier's network reviewed by a panel of health care providers, one of whom is knowledgeable in your scope of professional practice (but please note that this process and this committee may not be the same as the credentialing process or committee).

2. The right to submit the NJ Universal Physician Application or NJ Physician Recredentialing Application instead of carriers forms.

3. The right to receive a written decision regarding the application to participate within 90 days of providing the complete application. 

4. The right to request and review the factors considered by the committee in reviewing applications.

5. The right to file complaints on your own behalf or on the behalf of your patient, with your patient's consent, without fear of retaliation, and to have those complaints resolved.

6. The right to communicate openly with patients about all diagnostic testing and treatment options.

7. The right to act as an advocate for your patient in seeking appropriate, medically necessary health services.

8. The right to speak with the doctor who, acting on behalf of the carrier, disapproves or limits approval of a request for covered services, and receive a written statement denying the approval upon request.

9. The right to file with a carrier an internal Stage 1 and Stage 2 appeal of a disapproval or limited approval of covered services on behalf of your patient, with your patient's specific consent.

10. The right to obtain a written decision at the conclusion of each stage of the internal appeal process explaining why the carrier's prior decision is being upheld (if that is the case), and explaining how to proceed to the next level of appeal.

11. The right to pursue an external appeal through the Independent Health Care Appeals Program (IHCAP) on behalf of your patient, with the patient's consent, and obtain a written decision from the Independent Health Care Appeals Program upon the conclusion of the appeal review process.

12. The right to receive a periodic accounting of withhold amounts.

13. The right to provide input in the clinical criteria and protocols adopted by the carrier, pursuant to a system for the provision of such input established by the carrier.

14. The right to appeal claims payment issues within 90 days following a claims determination, and then take matters of $1,000 or more to the New Jersey Program for Independent Claims Payment Arbitration (PICPA).
15. The right to aggregate claims to attain the $1,000 PICPA threshold.
The following additional rights apply to health care professionals:

1. The right to at least 90-days prior written notice of termination of the contract, and the right to request a hearing, if the termination is to occur on other than the renewal or anniversary date of the contract, unless the termination is based on a belief that you have committed a fraud, breached the terms of the contract, or are an imminent danger to a patient or the public health, safety and welfare.

2. The right to request a written reason for the termination, if one is not provided with the notice of termination.

3. The right to request a hearing within 10 business days of receipt of the notice of termination, and to have the hearing held within 30 days of the request for the hearing.

4. The right to have the hearing held before a panel of at least three people, one of whom is in the same or a substantially similar discipline and specialty as you, and to be present at the hearing with representation.

5. The right to receive in writing the decision of the panel within 30 days following the close of the hearing (unless the panel requests an extension). The decision must specify the reasons for the panel's decision. If the panel recommends conditional reinstatement, the decision must include any conditions and time periods for conditional reinstatement, and the consequences for failing to meet the conditions.

Your Responsibilities

If you are a contracted health care provider, providing services in-network, you may not bill, or "balance bill," the carrier's covered individuals for covered services, except with respect to applicable deductibles, coinsurance amounts or copayments, regardless of whether you believe the amount of money you have been or will be paid by the carrier is appropriate or sufficient. Depending upon the terms of the contract, even if the covered services are determined not to be medically necessary, in whole or in part, you may be precluded from billing the patient should the services be rendered. You are responsible for knowing and understanding the terms of your contract with the carrier, and complying with the terms of that contract.

If you are a health care professional, the HCQA also requires that you continue to treat patients for a period of time following the termination of the contract between you and the carrier (or intermediary) consistent with all of the terms of the terminated contract. Generally, this time period is four months, but you may have a greater obligation if the following conditions are present:

1. For post-operative care, you have to continue to provide follow-up care for up to six months following termination of the contract.

2. For oncological treatment or psychiatric treatment, you have to continue to provide care for up to one year following termination of the contract.

3. For obstetrical care, you have to continue to provide care up to six weeks after delivery.

The continuation of treatment in all instances is at the option of the patient. The duration of treatment need not be longer than what is medically necessary in any instance. If there is a dispute as to whether the duration of treatment is medically necessary, a decision adverse to the patient made by the carrier can be appealed, just as any utilization management decision is appealed.
Notice of Intent to File an Appeal

If you are a health care provider appealing a utilization management determination with the consent of your patient, you are required to provide notice to the patient prior to filing the utilization management appeal at internal Stage 1 and Stage 2 as well as prior to filing a Stage 3 appeal with the IHCAP.  You also must honor a patient’s revocation of consent to representation in utilization management appeals.

If you are a hospital, you are required to have adequate staff available from 9 a.m. until 5 p.m. daily to respond to authorization requests (and subsequent requests for additional information) within the timeframes established by law.

OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.
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New Jersey Department of Banking and Insurance