ASSEMBLY, No. 2715
STATE OF NEW JERSEY
INTRODUCED FEBRUARY 3, 1997
By Assemblyman AUGUSTINE and Assemblywoman VANDERVALK
An Act concerning dispute resolution procedures for health care providers and supplementing Title 26 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. This act shall be known and may be cited as the "Health Care Provider Dispute Resolution Act."
2. As used in this act:
"Commissioner" means the Commissioner of Health and Senior Services.
"Covered health care service" means a health care service provided to an enrollee of a health maintenance organization for which the health maintenance organization is obligated to pay benefits.
"Enrollee" means an individual who is enrolled with a health maintenance organization.
"Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered health care service to an enrollee. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.
"Health maintenance organization" means a health maintenance organization authorized to operate in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.).
3. a. Every health maintenance organization for which a certificate of authority to establish and operate a health maintenance organization in this State has been issued or continued shall establish a health care provider dispute resolution procedure which addresses grievances involving the termination of the health care provider, interpretations of the terms of the contract between the health care provider and the health maintenance organization, and payment issues regarding covered health care services.
The procedure shall include an internal appeal process and shall provide the health care provider with the right to pursue an external appeal to an independent arbitrator, appointed by the commissioner, following the exhaustion of the health maintenance organization's internal appeal process.
b. Within 120 days of the adoption of regulations by the commissioner, a health maintenance organization shall file its dispute resolution procedure with the commissioner. The procedure shall be deemed approved 120 days after filing if it is not affirmatively approved or disapproved within that 120 days. During the 120-day review period, the commissioner may request such amendments to the procedure as the commissioner deems necessary. Any subsequent amendments to a filed and approved procedure shall be deemed approved 120 days after filing if not affirmatively approved or disapproved within 120 days from the filing date.
4. The commissioner, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt regulations to carry out the purposes of this act.
5. This act shall take effect 60 days after enactment.
STATEMENT
This bill requires all health maintenance organizations in the State to establish a health care provider dispute resolution procedure which addresses grievances involving the termination of the health care provider, interpretations of the terms of the contract between the health care provider and the health maintenance organization, and payment issues regarding covered health care services.
The procedure shall include an internal appeal process and shall provide the health care provider with the right to pursue an external appeal to an independent arbitrator, appointed by the Commissioner of Health and Senior Services, following the exhaustion of the health maintenance organization's internal appeal process.
Health care provider includes licensed health care professionals and licensed health care facilities who provide covered health care services to enrollees of health maintenance organizations.
Requires health maintenance organizations to establish dispute resolution procedures for health care providers.