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Current as of January 01, 2024 | Updated by Findlaw Staff
Any denial of a request for prior authorization or limitation imposed by a payer on a requested service on the basis of utilization management determination shall be made by a physician who shall:
a. make the adverse determination under the clinical direction of a medical director of the payer who shall:
(1) be licensed in this State; and
(2) strictly follow a medical policy that has been developed and made available in accordance with P.L.2023, c. 296 (C.17B:30-55.1 et al.) and the “New Jersey Health Care Quality Act,” P.L.1997, c. 192 (C.26:2S-1 et seq.);
b. not be compensated by a payer based on the approval or denial rate of the reviewing physician; and
c. not be provided preferential treatment by a payer in the requests for prior authorization of the reviewing physician if that physician is also a network provider for the payer.
Cite this article: FindLaw.com - New Jersey Statutes Title 17B. Insurance 17B § 30-55.8 - last updated January 01, 2024 | https://codes.findlaw.com/nj/title-17b-insurance/nj-st-sect-17b-30-55-8/
FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.
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