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.
‹ Prev All New Jersey sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.