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New Jersey Statutes Title 52. State Government, Departments and Officers 52 § 17B-198

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<This section expired April 8, 2008, under the terms of L.2001, c. 371, § 15.>

Two or more independent physicians or dentists who are practicing in the service area of a carrier may jointly negotiate with a carrier and engage in related joint activity, as provided in this act, regarding non-fee-related matters which may affect patient care, including, but not limited to, any of the following:

a. the definition of medical necessity and other conditions of coverage;

b. utilization management criteria and procedures;

c. clinical practice guidelines;

d. preventive care and other medical management policies;

e. patient referral standards and procedures, including, but not limited to, those applicable to out-of-network referrals;

f. drug formularies and standards and procedures for prescribing off-formulary drugs;

g. quality assurance programs;

h. respective physician or dentist and carrier liability for the treatment or lack of treatment of covered persons;

i. the methods and timing of payments;

j. other administrative procedures, including, but not limited to, eligibility verification systems and claim documentation requirements for covered persons;

k. credentialing standards and procedures for the selection, retention and termination of participating physicians or dentists;

l. mechanisms for resolving disputes between the carrier and physicians or dentists, including, but not limited to, the appeals process for utilization management and credentialing determinations;

m. the health benefits or dental plans sold or administered by the carrier in which the physicians or dentists are required to participate;

n. the formulation and application of reimbursement methodology;

o. the terms and conditions of physician or dentist contracts, including, but not limited to, all products clauses, and the duration and renewal provisions of the contract;  and

p. the inclusion or alteration of a contractual term or condition, except when the inclusion or alteration is required by a federal or State regulation concerning that term or condition;  however, the restriction shall not limit a physician's or dentist's rights to jointly petition the federal or State government, as applicable, to change the regulation.

Cite this article: - New Jersey Statutes Title 52. State Government, Departments and Officers 52 § 17B-198 - last updated February 19, 2021 |

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