New Jersey § 17B:30-55.12 Adverse determinations, appeal, reviewed by physician.

New Jersey Statutes

§ 17B:30-55.12 — Adverse determinations, appeal, reviewed by physician.

New Jersey § 17B:30-55.12

Title 17BINSURANCE

This text of New Jersey § 17B:30-55.12 (Adverse determinations, appeal, reviewed by physician.) is published on Counsel Stack Legal Research, covering New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

N.J. Stat. Ann. § 17B:30-55.12 (2026).

Text

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 me

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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.