Bill > S3298

Introduced Session

This bill modifies current law requiring the collection of certain data from health insurers. Specifically, the bill requires, on an annual basis, that a payer, or a carrier or an organized delivery system who is doing business in New Jersey and is under a contractual obligation to pay insured claims, maintain, and the Department of Banking and Insurance to make publicly available, data on health benefit plan claims regarding various matters, including the number of claims originally denied that were appealed and the number of appeals sustained and overturned and the procedures of each medical specialty for which a claim is most frequently denied. Additional data may be collected as authorized by the department. A payer who is determined to have denied, without proper justification, at least 20 percent of claims received in a year is, as a penalty, to return to a covered person a dollar amount equal to the cost paid by the covered person for the services denied for coverage by the payer. Additionally, the bill modifies current law governing utilization management by establishing certain reporting requirements for data. Specifically, the bill requires that: (1) every claim submitted for utilization management be reviewed by at least one medical director employed by or contracted with a payer; and (2) payers submit annually to the Department of Human Services and the Department of Banking and Insurance and to publicly disclose, in a clear and conspicuous location on the payer's Internet website, certain information concerning the payer's claim rejection rates each year. Pursuant to the bill, a physician or medical director reviewing claims for a payer is required to include on all denial notices the physician or medical director's claim denial rate and the average amount of time it takes for the physician or medical director to review a claim. Furthermore, a physician or medical director reviewing claims for a payer is to include instructions, on all denial notices and explanation of benefits notices, explaining how to access consumer assistance through the Department of Banking and Insurance. Health insurance carriers are also required under the bill to disclose, in a clear and conspicuous location on the carrier's Internet website: (1) whether or not the carrier uses an automated utilization management system; and (2) how many claims were reviewed using the automated utilization management system in the previous year. Lastly, the bill authorizes the Department of Banking and Insurance to audit at any time a payer's automated utilization management system and the data the payer collects in using that system. Under the bill, an "automated utilization management system" means an automated system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the health benefits plan and which may use artificial intelligence or other type of software to automate the process of making recommendations or determinations.

Committee Categories

Jon Bramnick (R)*,  Tony Bucco (R)*, 

Introduced in the Senate, Referred to Senate Commerce Committee (on 05/20/2024)

Official Document