State Adopts Rules on Health Claims Processing & Payment Act

    By: Melinda Martinson, Esq. on Feb 08, 2018

    The Department of Banking & Insurance adopted regulations implementing the Health Claims Authorization Processing & Payment Act (HCAPPA) which was passed in 2006. MSNJ filed comments joined by the NJ Association of Osteopathic Physicians & Surgeons, NJ Society of Interventional Pain Physicians, New Jersey Society of Pathologists and the NJ State Society of Anesthesiologists. We are pleased that DOBI clarified a number of issues to our satisfaction.

    • With respect to out of network providers, DOBI clarified that the rule applies equally to in- and out of network providers.
    • DOBI further required carriers to post their internal appeal procedures on their external web sites to facilitate appeals by out of network providers.
    • We sought and received clarification that providers may aggregate like claims to reach the $1,000 threshold.
    • DOBI also clarified that patient consent is not necessary to arbitrate payment disputes so long as no confidential medical information is provided to the arbitrator.
    • We sought and received confirmation that the arbitration process is permissive, not mandatory.
    • Finally, DOBI clarified that a carrier may not delay payment based on a theoretical coordination of benefits concern; there must be something in the file to suggest other insurance.

    We are disappointed that DOBI did not require carriers to give individual notice to providers when they change claims submission processes. We argued that web site posting is not sufficient. We will continue to seek more meaningful notice to providers whenever possible. While DOBI did not heed any of our suggestions concerning the allegation of fraud to support the use of extrapolation, it did note that providers may file for arbitration or file a complaint with the Department.

    It should be noted that while DOBI chose not to include in the rule that failure by a carrier to provide a denial or timely authorization will result in the request being deemed to be approved, DOBI confirmed that this is a statutory requirement and is self-implementing.

    Released: February 8, 2018, 11:55 am | Updated: February 8, 2018, 3:14 pm
    Keywords: Announcements

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