N.J.S.A. 17B:30-55.12 — Adverse determinations, appeal, reviewed by physician.

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.

This is the verbatim text of N.J.S.A. 17B:30-55.12, retrieved from the New Jersey Legislature's public statute corpus. Statutes are amended periodically — for the most current version, check the external source link above. Kyzer is not a law firm and this page is not legal advice.