New_jersey Statute | Act | Code |Title 17 Corporations And Institutions For Finance And Insurance| US Code - US Statute

17:48A-7bb. Medical service corporation, coverage for prescription female contraceptives. 2. A medical service corporation that provides hospital or medical expense benefits for expenses incurred in the purchase of outpatient prescription drugs under a contract shall provide coverage under every such contract delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives. For the purposes of this section, ~prescription female contraceptives~ means any drug or device used for contraception by a female, which is approved by the federal Food and Drug Administration for that purpose, that can only be purchased in this State with a prescription written by a health care professional licensed or authorized to write prescriptions, and includes, but is not limited to, birth control pills and diaphragms. A religious employer may request, and a medical service corporation shall grant, an exclusion under the contract for the coverage required by this section if the required coverage conflicts with the religious employer@s bona fide religious beliefs and practices. A religious employer that obtains such an exclusion shall provide written notice thereof to prospective subscribers and subscribers. The provisions of this section shall not be construed as authorizing a medical service corporation to exclude coverage for prescription drugs that are prescribed for reasons other than contraceptive purposes or for prescription female contraceptives that are necessary to preserve the life or health of a subscriber. For the purposes of this section, ~religious employer~ means an employer that is a church, convention or association of churches or an elementary or secondary school that is controlled, operated or principally supported by a church or by a convention or association of churches as defined in 26 U.S.C.s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C.s.501(c)(3). The benefits shall be provided to the same extent as for any other outpatient prescription drug under the contract. This section shall apply to those contracts in which the medical service corporation has reserved the right to change the premium. L.2005,c.251,s.2. 17:48A-7.1. Group contracts; issuance; description; benefits; employees defined A medical service corporation may issue to a policyholder a group contract, covering at least 10 employees or members at the date of issue, if it conforms to the following description: (a) A contract issued to an employer or to the trustees of a fund established by one or more employers, or issued to a labor union, or issued to an association formed for purposes other than obtaining such contract, or issued to the trustees of a fund established by one or more labor unions or by one or more employers and one or more labor unions, covering employees and members of associations or labor unions. (b) A contract issued to cover any other group which the Commissioner of Insurance (hereinafter called the commissioner) determines may be covered in accordance with sound underwriting principles. Benefits may be provided for one or more members of the families or one or more dependents of persons who may be covered under a group contract referred to in (a) or (b) above. Family type contracts shall provide that the services applicable for children shall be payable with respect to a newly-born child of the subscriber, or his or her spouse from the moment of birth. The services for newly-born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities. If a subscription payment is required to provide services for a child, the contract may require that notification of birth of a newly-born child and the required payment must be furnished to the service corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31-day period. Group contracts which provide for services to the subscriber but not to family members or dependents of that subscriber, other than contracts which provide no dependent coverage whatsoever for the subscriber@s class, shall also provide services to newly-born children of the subscriber which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities, provided that application therefor and payment of the required subscription amount are made to include in said contract the coverage described in the preceding paragraph of this section within 31 days from the date of birth of a newborn child. A contract under which coverage of such a dependent terminates at a specified age shall, with respect to an unmarried child, covered by the contract prior to attainment of age 19, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon the covered employee or member for support and maintenance, not so terminate while the coverage of the employee or member remains in force and the dependent remains in such condition, if the employee or member has within 31 days of such dependent@s attainment of the termination age submitted proof of such dependent@s incapacity as described herein. The foregoing provisions of this paragraph shall apply retrospectively or prospectively to require a medical service corporation to insure as a covered dependent any mentally retarded or physically handicapped child of the applicant where the contract is underwritten on evidence of insurability based on health factors required to be set forth in the application. In such cases any contract heretofore or hereafter issued may specifically exclude such mentally retarded or physically handicapped child from coverage. Any group contract which contains provisions for the payment by the insurer of benefits for members of the family or dependents of a person in the insured group shall, subject to payment of the appropriate premium, provide that such family members or dependents be permitted to have coverage continued for at least 180 days after the death of the person in the insured group. The contract may provide that the term ~employees~ shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprietorships and partnerships if the business of the employer and such corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The contract may provide that the term ~employees~ shall include the individual proprietor or partners of an individual proprietorship or a partnership. The contract may provide that the term ~employees~ shall include retired employees. A contract issued to trustees may provide that the term ~employees~ shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship. A contract issued to the trustees of a fund established by the members of an association of employers may provide that the term ~employees~ shall include the employees of the association. L.1964, c. 105, s. 1. Amended by L.1966, c. 237, s. 2; L.1975, c. 110, s. 2; L.1976, c. 101, s. 3, eff. Oct. 7, 1976. 17:48A-7.2. Provisions applicable to group contracts The provisions of the act to which this act is a supplement shall apply to group contracts except that sections 5, 6, 7 and 10 of such act shall not apply. The word ~subscriber~ as used in said act means the policyholder under a group contract where the context so requires. L.1964, c. 105, s. 2. 17:48A-7.3. Group contract form Every group contract entered into by a medical service corporation with any policyholder shall be in writing and a contract form stating the terms and conditions thereof shall be furnished to the policyholder to be kept by him. No group contract form shall be used unless it contains the following provisions: (a) A statement of the contract rate payable to the medical service corporation by or on behalf of the policyholder for the original period of coverage, the time or times at which, the manner in which, the contract rate due is to be paid, and the basis, if any, on which the rate may subsequently be adjusted; (b) A provision that all contract rates due under the contract shall be paid by the policyholder, or by the designated representative of the policyholder, to the medical service corporation on or before the due date thereof or within such period of grace as may be specified therein; (c) A statement of the nature of the medical services to be paid for and the period during which such payments will be made, and if there are any services to be excepted, a detailed statement of such exceptions; (d) A provision that the contract, any endorsements or riders thereto, the application of the policyholder in whose name the contract is issued, a copy of which shall be attached to the contract, and the individual applications, if any, of the employees or members shall constitute the entire contract between the parties and that all statements contained in any such application for coverage shall be deemed representations and not warranties; (e) A provision that there shall be issued to the policyholder, for delivery to the employee or member, a certificate or other document which sets forth or summarizes the essential features of the coverage including the time, place and method for making claims for benefits; (f) A provision that all new employees or new members, as the case may be, in the groups or classes eligible for the coverage must be added to the eligible groups or classes; (g) A statement of the terms and conditions, if any, upon which the contract may be terminated or amended. Any notice to the policyholder shall be effective if sent by mail to the policyholder@s address as shown at the time on the corporation@s records. The notice to the policyholder as herein required shall be sent at least 30 days before the termination or amendment of the contract takes effect. Any such group contract may contain a provision that all medical services paid for by a medical service corporation shall be in accordance with the accepted medical practices in the community at the time, but the corporation shall not be liable for injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any officer or employee or on the part of any physician in the course of rendering medical services to persons covered. Any medical service corporation may classify persons covered whereby under specified circumstances a covered person may pay a participating physician for medical services an amount in addition to that payable by the corporation for medical services and the group contract shall contain the provisions thereof and specify such circumstances. L.1964, c. 105, s. 3. 17:48A-7.4. Participation agreements A medical service corporation of this State may enter into agreements to participate with other corporations in the issuance of group contracts to policyholders whose employees or members are located in more than one State. Such agreements may provide for experience rating, for a sharing of the premium, claims, and expenses by the participating corporations or for acceptance or ceding of the whole or portions of group risks on a reinsurance basis. Such agreements shall be filed with and approved by the commissioner before becoming effective. L.1964, c. 105, s. 4. 17:48A-7.5. Schedule of rates No medical service corporation shall issue group contracts which are not experience-rated pursuant to section 4 of this act, until it shall have filed with the commissioner a full schedule of the rates which are to apply to such contracts. The commissioner may disapprove such schedule at any time if he finds that such rates are excessive, inadequate or unfairly discriminatory. It shall be unlawful for any corporation to effect any such group contract according to such rates thereafter. L.1964, c. 105, s. 5. Amended by L.1967, c. 286, s. 4, eff. Jan. 23, 1968. 17:48A-7.6. Combined hospital-medical contract A medical service corporation and a hospital service corporation authorized to do business in this State may issue a combined contract providing for medical care and hospital care but no one of such corporations shall issue any such combined contract. Any one of such corporations may act as agent for the other without being required to obtain a license as an agent. L.1964, c. 105, s. 6. 17:48A-7.7. Review of determinations of commissioner of banking and insurance All determinations of the Commissioner of Banking and Insurance made under the provisions of this act, or the act to which this act is a supplement, shall be subject to review by the Superior Court in a proceeding in lieu of prerogative writ. L.1964, c. 105, s. 7. 17:48A-7.8. Review of practices, rules and procedures of medical service corporations All practices, rules, and procedures of a medical service corporation, involving termination or refusal to renew coverage, modification of coverage or rates in the case of persons classified as left-group, selection of risks, and underwriting classifications, shall be subject to review at any time by the commissioner and upon his request for information relative to any such practice, rule, or procedure the medical service corporation shall furnish such information in writing without delay. If in the opinion of the commissioner any such practice, rule, or procedure, is unjust, unfair, or inequitable, taking into consideration the nonprofit and tax-exempt status of the medical service corporation, he shall so notify the medical service corporation and fix a time and place for hearing before him or his designated representative at which the medical service corporation may be heard. Following such hearing, the commissioner may make an order based on the record of the proceeding. If such order be one of disapproval, it shall be unlawful for the corporation to continue such practice, rule, or procedure. Such disapproval by the commissioner shall be subject to review by the Superior Court in a proceeding in lieu of prerogative writ. L.1964, c. 105, s. 8. 17:48A-7.9. Adjustment of rates; experience rating formula; approval Group contracts, covering at least 50 employees or members, may provide for the adjustment of the rate of premium at the end of the first year or any subsequent year of insurance thereunder based on the experience thereunder both past and contemplated. No medical service corporation shall use any form of experience rating plan until it shall have filed with the commissioner the formulas to be used and the classes of groups to which they are to apply. The commissioner may disapprove the formulas or classes at any time if he finds that the rates produced thereby are excessive, inadequate or unfairly discriminatory or that the rates, formulas or classes are such as to prejudice the interests of persons who are eligible for medical services under contracts with the medical service corporation which are not subject to experience rating. Excluding those rating formulas applicable to groups the employees or members of which are located in more than one State and which are underwritten in participation with other corporation(s) of other State(s), no rating formula shall be approved by the commissioner unless it provides that the groups with better than average experience will be assessed a reasonable community charge. Any such rating formula may provide for the allowance of an equitable discount in the event the policyholder agrees to perform certain administrative and record keeping functions in connection with the routine maintenance of the group account. Nothing in this section shall preclude the medical service corporation from incorporating in the rate formula such claim cost and utilization trend factors as it deems necessary in its discretion so long as the rates produced are self-supporting and the formulas for classes do not prejudice the interests of persons who are eligible for medical services under contracts with the medical service corporation which are not subject to experience rating. For experience rated groups of 50 to 99 employees or members, the commissioner will have the authority to determine that rates charged depart from community rates in such a way as to assure continuity of rating principles with the community rated and experience rated groups of 100 or more. L.1970, c. 114, s. 1, eff. June 26, 1970. Amended by L.1979, c. 177, s. 1, eff. Aug. 29, 1979. 17:48A-7.10. Coverage provided by medical service corporation for subscriber@s child 3. a. A medical service corporation contract which provides hospital or medical expense benefits under which dependent coverage is available shall not deny coverage for a subscriber@s child on the grounds that: (1) The child was born out of wedlock; (2) The child is not claimed as a dependent on the subscriber@s federal tax return; or (3) The child does not reside with the subscriber or in the medical service corporation@s service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the contract with respect to the use of specified providers. b. If a child has coverage through a medical service corporation contract of a noncustodial parent, the medical service corporation shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through the child@s noncustodial parent@s coverage; (2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for covered services without the approval of the noncustodial parent; and (3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate. c. When a parent who is the subscriber is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the medical service corporation shall: (1) Permit the parent to enroll his child as a dependent, without regard to any enrollment season restrictions; (2) Permit the child@s other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child under the contract if the parent who is the subscriber fails to enroll the child; and (3) Not terminate coverage of the child unless the parent who is the subscriber provides the medical service corporation with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage. L.1995,c.288,s.3. 17:48A-7.11. Requirements applicable to State Medicaid 4. A medical service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other subscriber. L.1995,c.288,s.4. 17:48A-7.12 Medical service corporation to receive, transmit transactions electronically; standards. 3. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a medical service corporation or its agent or a subsidiary that processes health care benefits claims as a third party administrator, shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance that it will adopt and implement all of the standards to receive and transmit health care transactions electronically, according to the corresponding timetable, and otherwise comply with the provisions of this section, as a condition of its continued authorization to do business in this State. The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation requirement when it has been demonstrated to the commissioner@s satisfaction that compliance with the timetable for implementation will result in an undue hardship to a medical service corporation, or its agent, its subsidiary or its covered persons. b. Within 12 months of the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a medical service corporation or its agent or a subsidiary that processes health care benefits claims as a third party administrator shall use the standard health care enrollment and claim forms in connection with all group and individual contracts issued, delivered, executed or renewed in this State. c. Twelve months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a medical service corporation or its agent shall require that health care providers file all claims for payment for health care services. A covered person who receives health care services shall not be required to submit a claim for payment, but notwithstanding the provisions of this subsection to the contrary, a covered person shall be permitted to submit a claim on his own behalf, at the covered person@s option. All claims shall be filed using the standard health care claim form applicable to the contract. d. For the purposes of this subsection, ~substantiating documentation~ means any information specific to the particular health care service provided to a covered person. (1) Effective 180 days after the effective date of P.L.1999, c.154, a medical service corporation or its agent, hereinafter the payer, shall remit payment for every insured claim submitted by a covered person or health care provider, no later than the 30th calendar day following receipt of the claim by the payer or no later than the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s.1395u(c)(2)(B), whichever is earlier, if the claim is submitted by electronic means, and no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means, if: (a) the health care provider is eligible at the date of service; (b) the person who received the health care service was covered on the date of service; (c) the claim is for a service or supply covered under the health benefits plan; (d) the claim is submitted with all the information requested by the payer on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51) ; and (e) the payer has no reason to believe that the claim has been submitted fraudulently. (2) If all or a portion of the claim is not paid within the time frames provided in paragraph (1) of this subsection because: (a) the claim submission is incomplete because the required substantiating documentation has not been submitted to the payer; (b) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect; (c) the payer disputes the amount claimed; or (d) there is strong evidence of fraud by the provider and the payer has initiated an investigation into the suspected fraud, the payer shall notify the health care provider, by electronic means and the covered person in writing within 30 days of receiving an electronic claim, or notify the covered person and health care provider in writing within 40 days of receiving a claim submitted by other than electronic means, that: (i) the claim is incomplete with a statement as to what substantiating documentation is required for adjudication of the claim; (ii) the claim contains incorrect information with a statement as to what information must be corrected for adjudication of the claim; (iii) the payer disputes the amount claimed in whole or in part with a statement as to the basis of that dispute; or (iv) the payer finds there is strong evidence of fraud and has initiated an investigation into the suspected fraud in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (3) If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding or any other data required to be submitted with the claim was missing, the payer shall electronically notify the health care provider or its agent within seven days of that determination and request any information required to complete adjudication of the claim. (4) Any portion of a claim that meets the criteria established in paragraph (1) of this subsection shall be paid by the payer in accordance with the time limit established in paragraph (1) of this subsection. (5) A payer shall acknowledge receipt of a claim submitted by electronic means from a health care provider, no later than two working days following receipt of the transmission of the claim. (6) If a payer subject to the provisions of P.L.1983, c.320 (C.17:33A-1 et seq.) has reason to believe that a claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or refer the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (7) Payment of an eligible claim pursuant to paragraphs (1) and (4) of this subsection shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means and on or before the 40th calendar day following receipt of a claim submitted by other than electronic means. If payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of paragraph (2) or paragraph (3) of this subsection, the claims payment shall be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, for claims submitted by electronic means and the 40th calendar day for claims submitted by other than electronic means, following receipt by the payer of the required documentation or information or modification of an initial submission. If payment is withheld on all or a portion of a claim by a payer pursuant to paragraph (2) or (3) of this subsection and the provider is not notified within the time frames provided for in those paragraphs, the claim shall be deemed to be overdue. (8) (a) No payer that has reserved the right to change the premium shall deny payment on all or a portion of a claim because the payer requests documentation or information that is not specific to the health care service provided to the covered person. (b) No payer shall deny payment on all or a portion of a claim while seeking coordination of benefits information unless good cause exists for the payer to believe that other insurance is available to the covered person. Good cause shall exist only if the payer@s records indicate that other coverage exists. Routine requests to determine whether coordination of benefits exists shall not be considered good cause. (c) In the event payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of this paragraph, the claims payment shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means or on or before the 40th calendar day following receipt of a claim submitted by other than electronic means. (9) An overdue payment shall bear simple interest at the rate of 12% per annum. The interest shall be paid to the health care provider at the time the overdue payment is made. The amount of interest paid to a health care provider for an overdue claim shall be credited to any civil penalty for late payment of the claim levied by the Department of Human Services against a payer that does not reserve the right to change the premium. (10) With the exception of claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits, no payer shall seek reimbursement for overpayment of a claim previously paid pursuant to this section later than 18 months after the date the first payment on the claim was made. No payer shall seek more than one reimbursement for overpayment of a particular claim. At the time the reimbursement request is submitted to the health care provider, the payer shall provide written documentation that identifies the error made by the payer in the processing or payment of the claim that justifies the reimbursement request. No payer shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances: (a) in judicial or quasi-judicial proceedings, including arbitration; (b) in administrative proceedings; (c) in which relevant records required to be maintained by the health care provider have been improperly altered or reconstructed, or a material number of the relevant records are otherwise unavailable; or (d) in which there is clear evidence of fraud by the health care provider and the payer has investigated the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (11) (a) In seeking reimbursement for the overpayment from the health care provider, except as provided for in subparagraph (b) of this paragraph, no payer shall collect or attempt to collect: (i) the funds for the reimbursement on or before the 45th calendar day following the submission of the reimbursement request to the health care provider; (ii) the funds for the reimbursement if the health care provider disputes the request and initiates an appeal on or before the 45th calendar day following the submission of the reimbursement request to the health care provider and until the health care provider@s rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section are exhausted; or (iii) a monetary penalty against the reimbursement request, including but not limited to, an interest charge or a late fee. The payer may collect the funds for the reimbursement request by assessing them against payment of any future claims submitted by the health care provider after the 45th calendar day following the submission of the reimbursement request to the health care provider or after the health care provider@s rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section have been exhausted if the payer submits an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person@s bill. (b) If a payer has determined that the overpayment to the health care provider is a result of fraud committed by the health care provider and the payer has conducted its investigation and reported the fraud to the Office of the Insurance Fraud Prosecutor as required by law, the payer may collect an overpayment by assessing it against payment of any future claim submitted by the health care provider. (12) No health care provider shall seek reimbursement from a payer or covered person for underpayment of a claim submitted pursuant to this section later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an appeal submitted pursuant to subsection e. of this section or the claim is subject to continual claims submission. No health care provider shall seek more than one reimbursement for underpayment of a particular claim. e. (1) A medical service corporation or its agent, hereinafter the payer, shall establish an internal appeal mechanism to resolve any dispute raised by a health care provider regardless of whether the health care provider is under contract with the payer regarding compliance with the requirements of this section or compliance with the requirements of sections 4 through 7 of P.L.2005, c.352 (C.17B:30-51 through C.17B:30-54). No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of an appeal pursuant to this subsection. The payer shall conduct the appeal at no cost to the health care provider. A health care provider may initiate an appeal on or before the 90th calendar day following receipt by the health care provider of the payer@s claims determination, which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance which shall describe the type of substantiating documentation that must be submitted with the form. The payer shall conduct a review of the appeal and notify the health care provider of its determination on or before the 30th calendar day following the receipt of the appeal form. If the health care provider is not notified of the payer@s determination of the appeal within 30 days, the health care provider may refer the dispute to arbitration as provided by paragraph (2) of this subsection. If the payer issues a determination in favor of the health care provider, the payer shall comply with the provisions of this section and pay the amount of money in dispute, if applicable, with accrued interest at the rate of 12% per annum, on or before the 30th calendar day following the notification of the payer@s determination on the appeal. Interest shall begin to accrue on the day the appeal was received by the payer. If the payer issues a determination against the health care provider, the payer shall notify the health care provider of its findings on or before the 30th calendar day following the receipt of the appeal form and shall include in the notification written instructions for referring the dispute to arbitration as provided by paragraph (2) of this subsection. The payer shall report annually to the Commissioner of Banking and Insurance the number of appeals it has received and the resolution of each appeal. (2) Any dispute regarding the determination of an internal appeal conducted pursuant to paragraph (1) of this subsection may be referred to arbitration as provided in this paragraph. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings. Any party may initiate an arbitration proceeding on or before the 90th calendar day following the receipt of the determination which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance. No dispute shall be accepted for arbitration unless the payment amount in dispute is $1,000 or more, except that a health care provider may aggregate his own disputed claim amounts for the purposes of meeting the threshold requirements of this subsection. No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection. (3) The arbitrator shall conduct the arbitration proceedings pursuant to the rules of the arbitration entity, including rules of discovery subject to confidentiality requirements established by State or federal law. (4) An arbitrator@s determination shall be: (a) signed by the arbitrator; (b) issued in writing, in a form prescribed by the Commissioner of Banking and Insurance, including a statement of the issues in dispute and the findings and conclusions on which the determination is based; and (c) issued on or before the 30th calendar day following the receipt of the required documentation. The arbitration shall be nonappealable and binding on all parties to the dispute. (5) If the arbitrator determines that a payer has withheld or denied payment in violation of the provisions of this section, the arbitrator shall order the payer to make payment of the claim, together with accrued interest, on or before the 10th business day following the issuance of the determination. If the arbitrator determines that a payer has withheld or denied payment on the basis of information submitted by the health care provider and the payer requested, but did not receive, this information from the health care provider when the claim was initially processed pursuant to subsection d. of this section or reviewed under internal appeal pursuant to paragraph (1) of this subsection, the payer shall not be required to pay any accrued interest. (6) If the arbitrator determines that a health care provider has engaged in a pattern and practice of improper billing and a refund is due to the payer, the arbitrator may award the payer a refund, including interest accrued at the rate of 12% per annum. Interest shall begin to accrue on the day the appeal was received by the payer for resolution through the internal appeals process established pursuant to paragraph (1) of this subsection. (7) The arbitrator shall file a copy of each determination with and in the form prescribed by the Commissioner of Banking and Insurance. f. As used in this section, ~insured claim~ or ~claim~ means a claim by a covered person for payment of benefits under an insured medical service corporation contract for which the financial obligation for the payment of a claim under the contract rests upon the medical service corporation. g. Any person found in violation of this section with a pattern and practice as determined by the Commissioner of Banking and Insurance shall be liable to a civil penalty as set forth in section 17 of P.L.2005, c.352 (C.17B:30-55). L.1999,c.154,s.3; amended 2005, c.352, s.11. 17:48A-7.13 Coverage for certain dependents until age 30 by medical service corporation. 2. a. As used in this section, ~dependent~ means a subscriber@s child by blood or by law who: (1) is less than 30 years of age; (2) is unmarried; (3) has no dependent of his own; (4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and (5) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.). b. (1) A medical service corporation contract that provides coverage for a subscriber@s dependent under which coverage of the dependent terminates at a specific age before the dependent@s 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this section, shall, upon application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent@s 30th birthday. (2) Nothing herein shall be construed to require: (a) coverage for services provided to a dependent before the effective date of this section; or (b) that an employer pay all or part of the cost of coverage for a dependent as provided pursuant to this section. c. (1) A dependent covered by a subscriber@s contract, which coverage under the contract terminates at a specific age before the dependent@s 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent@s 30th birthday: (a) within 30 days prior to the termination of coverage at the specific age provided in the contract; (b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the contract previously terminated; or (c) during an open enrollment period, as provided pursuant to the contract, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the open enrollment period. (2) For 12 months after the effective date of this section, a dependent who qualifies for dependent status as set forth in subsection a. of this section, but whose coverage as a dependent under a subscriber@s contract terminated under the terms of the contract prior to the effective date of this section, may make a written election to reinstate coverage under that contract as a dependent pursuant to this section. d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the contract. If coverage is modified under the contract for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the contract, the coverage shall also be modified in the same manner for the dependent. (2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability. e. (1) The subscriber@s contract may require payment of a premium by the subscriber or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent@s written election for coverage pursuant to subsection c. of this section. The premium shall not exceed 102% of the applicable portion of the premium previously paid for that dependent@s coverage under the contract prior to the termination of coverage at the specific age provided in the contract. (2) The applicable portion of the premium previously paid for the dependent@s coverage under the contract shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the contract@s rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result. (3) Payments of the premium may, at the election of the payor, be made in monthly installments. f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following: (1) the dependent is disqualified for dependent status as set forth in subsection a. of this section; (2) the date on which coverage ceases under the contract by reason of a failure to make a timely payment of any premium required under the contract by the subscriber or dependent for coverage provided pursuant to this section. The payment of any premium shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the contract; or (3) the date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber. Nothing herein shall be construed to permit a medical service corporation to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent@s prior disqualification pursuant to paragraph (1) of this subsection. g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a subscriber: (1) in the certificate of coverage prepared for subscribers by the medical service corporation on or about the date of commencement of coverage; and (2) by the subscriber@s employer: (a) on or before the coverage of a subscriber@s dependent terminates at the specific age as provided in the contract; (b) at the time coverage of the dependent is no longer provided pursuant to this section because the dependent is disqualified for dependent status as set forth in subsection a. of this section, except this employer notice shall not be required when a dependent no longer qualifies based upon paragraph (1) or (3) of subsection a. of this section; (c) before any open enrollment period permitting a dependent to make a written election for coverage pursuant to subsection c. of this section; and (d) immediately following the effective date of this section, with respect to information concerning a dependent@s opportunity, for 12 months after the effective date of the section, to make a written election to reinstate coverage under a contract pursuant to paragraph (2) of subsection c. of this section. h. This section shall apply to those contracts in which the medical service corporation has reserved the right to change the premium. L.2005,c.375,s.2.

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