17B:30-55.8 Prior authorization, denial, limitation imposed by payer, physician, scope of actions. 9. 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. L.2023, c.296, s.9.
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