INSURANCE

DEPARTMENT OF BANKING AND INSURANCE

DIVISION OF INSURANCE

Electronic Receipt and Transmission of Health Care Claim Information:

Standard Enrollment and Claim Forms

Proposed New Rules: N.J.A.C. 11:22-3

Authorized By: Karen L. Suter, Commissioner, Department of Banking and Insurance

Authority: N.J.S.A. 17:1-8.1 and 17:1-15e and P.L. 1999, c.154 - The Health Information Electronic Data Interchange Technology Act ("HINT")

Proposal Number: PRN 2001-63

Submit comments by April 4, 2001 to:

Karen Garfing, Assistant Commissioner
Regulatory Affairs
Department of Banking and Insurance
20 West State Street
P.O. Box 325
Trenton, NJ 08625-0325

The agency proposal follows:

Summary

On July 1, 1999, the Health Information Electronic Data Interchange Technology Act ("The Act") P.L. 1999, c. 154, was adopted. The Act, which is commonly known as "HINT," requires the Commissioner of the Department of Banking and Insurance ("Commissioner" and/or "Department") to adopt, by regulation, a timetable that requires all hospital, medical and health service corporations, individual and group health insurers, group health insurers, health maintenance organizations, dental service corporations, dental plan organizations and prepaid prescription service organizations ("payers") to implement systems for the electronic receipt and transmission of health care claim information.

These electronic systems will encompass the fullest possible range of health care related information exchanges, including receipt and transmission of health claims; enrollment and disenrollment information; eligibility for coverage; health care payment and remittance advice; health care premium payments; first report of injuries; health claim status; and referral certification requests and authorization information. Ultimately, all health care transactions will be transmitted electronically using common electronic formats and code sets acceptable by all health care payers.

HINT requires the Department to adopt rules that:

  1. Establish one set of standard health care enrollment and claim forms in paper and electronic format to be used by all payers authorized to do business in New Jersey;

  2. Fix timetables for the implementation of the use of enrollment and claim forms (electronic and paper formats) in all health care related transactions by all payers authorized to do business in this State;

  3. Create a procedure for the receipt and processing of operational status reports in which payers report to the Department their ability to achieve compliance with the timetables for electronic processing of enrollment and claim information;

  4. Develop procedures to dispose of requests for extensions of time and waivers from compliance that are to be filed by payers unable to comply with the timetables;

  5. Acquire, assemble and report payer compliance; extensions of time granted; any waivers granted; and reasons therefor to the Governor and Legislature; and

  6. Reduce and consolidate wherever possible, paper health care transactions by all payers and health care service providers.

The implementation of the requirements mandated by HINT is a part of a collaborative effort by the Department with the Department of Health and Senior Services ("DHSS"), Thomas A. Edison State College and the New Jersey Institute of Technology ("NJIT"). This effort began in 1993, when the HINT Advisory Council was formed by members of the Legislature together with other essential stakeholders from government, providers, health care facilities, health care payers and members of industry to weigh the value of electronic data interchange ("EDI") in handling health care claims information. In March 1995, the HINT Advisory Council reported the potential for enormous savings upon implementation of EDI in the health care industry. The work of the HINT Advisory Council continued until its efforts eventually resulted in the Act. Notwithstanding this effort, it was recognized that New Jersey could not practicably move forward without coordination regionally and nationally.

On a parallel track with the New Jersey HINT initiative, the Federal Government enacted the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") (P.L. 104–191). Among other things, HIPAA required the United States Department of Health and Human Services ("HHS") to develop national standards for the administrative simplification of health care transactions. Starting in mid 1998, HHS proposed a series of administrative regulations that will create the architecture for a national system of health care claims transactions by EDI. This HHS system is monumental in scope and will include transaction and code sets for processing health care claims information; national provider, employer and plan identifiers; and privacy and security standards, claims attachments and enforcement.

In recognition of the need for national standards and structure, HINT imposed a condition precedent on the implementation of EDI systems in New Jersey: HHS must adopt uniform electronic transaction and code sets before the New Jersey HINT timetable starts to run.

On July 17, 2000, at 45 CFR Section 162.100 et seq., HHS promulgated rules establishing the transaction and code set standards as well as the related administrative simplification requirements imposed by HIPAA. These Federal rules and health care transaction standards are effective October 16, 2000, thus triggering the HINT mandates.

In an effort to alert payers to the HHS adoption and to obtain some understanding of the then current status of payer's plans for development of HINT/HIPAA complaint systems, the Department issued Order A00-138 on August 29, 2000. The Order required all affected payers to report to the Department specific details about the extent of any compliance plans and efforts. The Department was gratified to learn from the responses that most of the responding payers had already established project development teams and were making specific plans to achieve compliance with the anticipated requirements.

The Department also notes that the Act does not require providers to implement electronic systems for the processing of health care transactions. The Act merely states that 12 months after HINT becomes operative all health care providers shall file claims on behalf of patients unless the patient elects to personally file the claim. It should be noted, however, that the Act does provide incentives where providers file electronically. For instance, electronically filed claims must be paid in 30 days while paper claims must be paid in 40 days. Electronically filed claims must be acknowledged by payers within two days of receipt, and paper claims within 15 days of receipt. The Department recently adopted rules that implement the prompt pay aspect of the Act at N.J.A.C. 11:22-1 (See 33 N.J.R. 105(a)).

The Department, in consultation with the Department of Health and Senior Services and the HINT Advisory Board (established in accordance with the Act), is now proposing a new subchapter for the electronic receipt and transmission of health care claims information by EDI.

Proposed N.J.A.C. 11:22-3.1 sets forth the purpose and scope of the subchapter.

Proposed N.J.A.C. 11:22-3.2 contains the definitions which are used in the new subchapter. These include "claim," "Commissioner," "covered person," "covered service or supply," "health care provider," "provider," "health benefit payer," "payer," "health care transaction," "standard," "system" and "small employer health benefits plan."

Proposed N.J.A.C. 11:22-3.3 contains the standard enrollment and claim forms in paper and electronic format as required by the Act.

Proposed N.J.A.C. 11:22-3.4 will establish the timetables for payers to comply with the provisions of the Act. These timetables as proposed are expressed as a number of days after the adoption of the rules. When the adoption occurs, the Department will calculate the precise date and it will be added to the rule. This section also contains a provision for payers to file operational status reports pursuant to HINT, in which they report the development and implementation of HINT compliant systems.

Proposed N.J.A.C. 11:22-3.5 establishes the procedure for payers to petition the Commissioner for extensions of time and/or waivers from the obligations established by HINT and these rules.

Proposed new rule N.J.A.C. 11:22-3.6 establishes the obligation that requires payers to accept health care claims only from a licensed professional filing on behalf of the patient unless the patient elects to file the claim directly. The Act provides that twelve months after the adoption of these rules, all payers shall require that all providers, and not patients, shall file claims for payment. The only exception to this is where the patient elects to file the claim directly. In addition, the rule also provides, consistent with the Act, that claims not filed in a timely manner may be denied pursuant to the guidelines contained in this section.

Proposed N.J.A.C. 11:22-3.7 establishes the timetable for the sequential implementation of the remaining transaction and code sets. HINT requires that enrollment and claims forms be implemented within one year of the adoption of these rules. The remaining HHS transaction and code sets will be implemented by October 16, 2002, in accordance with the schedule and standards established in the HHS rules.

Proposed N.J.A.C. 11:22-3.8 establishes provisions for the computation of time limits when payers and/or providers use the services of a clearinghouse for the transmission and/or receipt of electronic claims information.

Proposed N.J.A.C. 11:22-3.9 provides that all information and materials obtained or used by health care payers, their agents and vendors in the processing of health care claims are subject to the provisions of N.J.S.A. 17:23A-1 et seq. On December 28, 2000, HHS adopted Federal privacy and security rules that will apply to all electronic and paper health care transactions in the entire country. (See 45 CFR 160.101 et seq.) These Federal rules will not become effective until March 2003. Between now and the effective date, many issues need to be addressed and resolved. These include the coordination with other Federal and State laws dealing with privacy and security. When these issues are resolved, further review of this provision may be necessary. However, HINT does not permit any delay in implementation pending the effective date of privacy and security rules. In the meantime, the Department will continue to apply the New Jersey statutory law that applies to these transactions unless it is preempted by more restrictive Federal law.

Proposed N.J.A.C. 11:22-3.10 will require that payers implement appropriate fraud detection and prevention practices in order to prevent, wherever possible, the payment of fraudulently submitted claims, and to report cases of suspected fraud to the Office of the Insurance Fraud Prosecutor in accordance with HINT and N.J.S.A. 17:33A-1 et seq.

Proposed N.J.A.C. 11:22-3.11 establishes the penalties for failure to comply with these provisions.

Social Impact

The proposed new subchapter will have a positive impact on the public and the health care community by lowering the cost associated with the administration of health care claims. As these rules for the electronic transmission of health care claims are implemented, the result in savings may be passed on to consumers in the form of lower premiums and greater coverages.

Economic Impact

The proposed new subchapter should ultimately have a positive economic impact on insureds and persons covered under health benefit plans. Claims and other health care transactions should be processed more quickly and efficiently resulting in less overall costs of administration. Where approval is needed for tests, treatment and referral to other health care professionals, the necessary certification and authorization should be obtained more rapidly and with a greater degree of predictability.

There is no doubt that health care benefits payers, their agents and vendors will be required by these rules to expend substantial funds to achieve compliance with these rules. Some currently existing processes will need to be abandoned and other new and costly systems implemented. Precise estimates of the cost of implementation are not available; however, some experts have opined that compliance with HINT and HIPAA will equal or exceed that required for Y2K preparedness.

Notwithstanding the substantial cost in achieving compliance, studies show that the savings will far exceed the cost of investment. Where paper claims are processed at a rate of dollars per claim, electronic claims can be processed at a rate of pennies per claim. Thus, a return on investment should be realized by all payers within the foreseeable future.

These rules do not require medical providers to implement electronic systems for the filing of claims. Medical providers are simply required, one year after the date of the adoption of these rules, to file claims on behalf of their patients. There is no question, however, that providers are being encouraged to file claims electronically. HINT, HIPAA and these rules should result in a quick return on investment for those medical providers investing in electronic systems. Providers should also find that claims are acknowledged and paid much faster.

It should also be noted that the expenditures required by these rules are mandated by HINT and will also be required for compliance with HIPAA. As a result, the Department, in consultation with DHSS, Thomas A. Edison State College and NJIT, is proposing these rules to provide a regulatory framework within which there can be strategic implementation of the obligations imposed by HINT and HIPAA. In conclusion, all significant interests should ultimately benefit from compliance with these rules.

Federal Standards Statement

A Federal standards analysis is required when any State agency proposes to adopt, readopt or amend State rules that exceed any Federal standards or requirements, and must include in the rulemaking document a comparison of Federal law.

The Department has determined that these rules, which are based upon requirements established in the Act, do not exceed any current Federal standards insofar as payers will be required to implement systems for the electronic transmission of health care claims and enrollment information many months before compliance is required by Federal regulations.

October 16, 2002 is the Federal deadline by which all payers must be HIPAA compliant, notwithstanding the early implementation mandated by New Jersey’s HINT requirements. HINT and these rules require that payers implement systems for claims and enrollment transactions 12 months after these rules are adopted. The accelerated timetables are mandated by the Act and these rules reflect the requirements of the statute.

In Section 1178 of HIPAA, Congress adopted the general rule that the Federal provisions will preempt state law that is contrary to the Federal rules. There are three exceptions to this general rule: (1) state laws and rules to prevent fraud or abuse; (2) state laws and rules enforcing a state’s controlled dangerous substances laws; and (3) state laws or rules that relate to the privacy of individually identifiable health information. While it may be that the HIPAA privacy rules will ultimately be more stringent than New Jersey’s Insurance Information Privacy Act, they will not become effective until after these rules are adopted. Thus, in the absence of operative HIPPA rules on this subject of privacy, the Department is compelled to follow State law until such time as the Federal rules may be effective. The Department will re-visit this issue as the effective date of the HIPAA privacy rules approaches.

The Department also wishes to note that it considered the application of the Gramm-Leach-Bliley Act ("GLB"), Pub. L. 106-102, §§ 501 et seq. to these proposed rules. It appears that GLB may limit the ability of financial institutions to disclose personal information about consumers to other parties and require that customers be advised about the institution’s privacy policies and practices. However, of significance is the fact that Congress did not specifically state that GLB was applicable to health insurers. As a result, it now appears to the Department that only the New Jersey Insurance Information Practices Act applies to the subject matter of the proposed rules. Thus, the Department has determined in the proposed rules to make clear that payers, their agents and vendors are processing information relative to insurance claims and, thus, the provisions of N.J.S.A. 17:23A-1 et seq. (the Insurance Information Practices Act) apply. The Department will act as deemed appropriate with regard to future privacy and security issues when HHS’s position becomes clearer.

Jobs Impact

The Department anticipates that jobs may be generated as a consequence of the proposed new subchapter. The implementation of these rules will require the development of elaborate new EDI systems which are certain to generate new employment opportunities. In addition, new opportunities may be manifested as clearinghouse and other vendors seek to provide EDI services to medical providers and payers. The Department is not in possession of any workforce development studies, but welcomes input on this subject from all knowledgeable commenters.

Agriculture Industry Impact

The Department does not expect any impact on the agriculture industry from the proposed new subchapter.

Regulatory Flexibility Analysis

The new subchapter will apply to all hospital service corporations; medical service corporations; health service corporations; health insurers issuing individual policies of insurance; health insurers issuing group policies of insurance; health maintenance organizations; dental service corporations; dental plan organizations; and prepaid prescription service organizations. Some of these payers are "small businesses" as that term is defined in the Regulatory Flexibility Act, N.J.S.A. 52:14B-16 et seq. To the extent that the subchapter will apply to such small businesses, they will be required to incur costs necessary for the development and/or implementation of HINT compliant systems. Because the Act which mandates these obligations does not allow for any small business exception in the deployment of these systems, all payers, regardless of size, will be required to comply with these requirements.

The Department does note, however, that certain small payers have been granted additional time to achieve compliance with the HIPAA requirements and thus the Department, upon application, will extend the time for small payers to comply. The Department is defining small payers in accordance with the definition used by HHS, which are those group health plans having less than 50 participants and/or $5 million in annual receipts.

The provisions of proposed N.J.A.C. 11:22-3.5(c) will permit small employer health benefits payers to receive an additional six months time for compliance upon application to and approval by the Department. Such payers must submit proof that the group plan has less than 50 participants and/or less than $5 million annual gross receipts.

While HINT does not impose any obligation on providers to file claims electronically, it does provide certain incentives that should make the electronic filing option more compelling in the eyes of providers. As noted above, 12 months after adoption of these rules, payers will only accept claims filed by providers and not from patients, unless undertaken by the patient. Also, electronically filed claims will be paid in 30 days and acknowledged in two days while paper claims will be paid in 40 days and acknowledged in 10 days. In electronic claims the acknowledgement process will be an automatic response from the payer’s system once it passes through a routine screening process, whereas payer claims will be subject to the uncertainties of manual handling.

Full text of the proposed new subchapter follows:

SUBCHAPTER 3. Electronic Receipt and Transmission of Health Care Claims

11:22-3.1 Purpose and scope

  1. Pursuant to N.J.S.A. 17B:30-23 et. seq., P.L. 1999, c. 154 (the Health Information Electronic Data Interchange Technology Act ("HINT" or "the Act")), the purpose of this subchapter is to establish timetables for the introduction and implementation of systems for the electronic receipt and transmission of health care claim information, including, but not limited to, eligibility, premium payments, reports of injury, claim status, referral requests, authorization for referral, enrollment, disenrollment, and other health care claims transactions in accordance with the standards developed by the United States Department of Health and Human Services (hereinafter referred to as "DHHS") for the electronic administration of health care benefits.
  2. In accordance with N.J.S.A. 17B:30-23b, this subchapter also establishes one set of standard health care enrollment and claim forms in paper and electronic formats to be used by all health care benefit payers referred to in (d) below.

  3. Pursuant to N.J.S.A. 45:1-10.1 and 26:2H-12.12, this subchapter also establishes rules requiring health care professionals, institutions and facilities to file claims on behalf of their patients when seeking payment or reimbursement of health care claims.

  4. The subchapter applies to all hospital service corporations; medical service corporations; health services corporations; health insurers issuing individual policies of insurance; health insurers issuing group policies of insurance; health maintenance organizations; dental service corporations; dental plan organizations; prepaid prescription service organizations; and all health care providers.

11:22-3.2 Definitions

The following words, phrases and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.

"Claim" or "insured claim" means a request by a covered person, a participating health care provider, or a nonparticipating health care provider who has received an assignment of benefits from the covered person, for payment relating to health care services or supplies or dental services or supplies covered under a health benefits plan or dental plan issued by a carrier.

"Commissioner" means the Commissioner of the Department of Banking and Insurance.

"Covered person" means a person on whose behalf a payer has an obligation to pay benefits for health care services pursuant to a plan, policy, contract, certificate, or any other document.

"Covered service or supply" means a health care service or supply provided to a covered person under a health benefits or dental plan for which the payer is obligated to pay benefits or provide services or supplies subject to any applicable deductible, coinsurance or co-payment.

"Health benefit payer" or "payer" means those entities identified in N.J.A.C. 11:22-3.1(d) above that are subject to the provisions of this chapter.

"Health care provider" or "provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service or supply defined by the health benefits or dental plan. Health care provider includes, but is not limited to, a physician, dentist or other health care professional licensed pursuant to Title 45 of the Revised Statutes; a hospital and other health care facility licensed pursuant to Title 26 of the Revised Statutes; and/or a purveyor of prescription, pharmaceutical products or durable medical goods or equipment.

"Health care transaction" or "transaction" means the exchange of information between two or more parties to carry out the financial and administrative activities related to coverage under a health benefits or dental plan, including, but not limited to, health claims and equivalent encounter information, health care payment and admittance advice, health claims status, enrollment and disenrollment in a health plan, eligibility for a health plan, health or dental plan premium payments, first report of injury, deferral certification and authorization and health care attachments.

"Standard" means a prescribed set of rules, conditions, transaction sets or requirements concerning classification of components, specification of materials, performance or operations, or delineation of procedures, in describing products, systems, services or practices.

"System" or "system for the electronic receipt and transmission of health care claim information" means that electronic network established in accordance with 42 U.S.C. §§ 1320d et seq. for the transaction of health care related information including:

  1. Health claims or equivalent encounter information, including institutional, professional, pharmacy and dental health claims;

  2. Enrollment and disenrollment in a health plan;

  3. Eligibility for a health plan; health care payment and remittance advice;

  4. Health care premium payments;

  5. First report of injury;

  6. Health claim status; and

  7. Referral certification and authorization.

"Small Employer Health Benefits Plan" means any plan identified as such by N.J.S.A. 17B:27A-17.

11:22-3.3 Standard enrollment and claim forms

  1. 45 C.F.R. 162.1101, Subpart K, the Health Care Claims or Equivalent Encounter Information Standard, and 45 CFR 162.1501, Subpart O, the Enrollment and Disenrollment in a Health Plan Standard, are adopted by the Department, in consultation with the Department of Health and Senior Services, as the electronic standard format for enrollment, disenrollment and claim forms, and are incorporated and made a part herein by reference.

  2. The UB-92, HCFA 1450 (the uniform claim for use by health care institutions and facilities) and the HCFA 1500 (the uniform claim for health care providers) are recognized and adopted by the Department, in consultation with the New Jersey Department of Health and Senior Services, as the paper standard format for claims by medical institutions, facilities and providers. These forms are located at the website maintained by the Federal Health Care Financing Administration (www.hcfa.gov/forms/) and incorporated herein by reference.

  3. The paper standard format for a universal enrollment form is located at subchapter Appendix Exhibit 1 and is incorporated herein by reference.

11:22-3.4 Timetable and operational status reports

    1. On or before (12 months after the effective date of these rules) health benefit payers shall use the standard electronic claim and enrollment forms adopted at N.J.A.C. 11:22-3.3(a).
    2. On or before (180 days after the effective date of these rules) health benefit payers shall file with the Department the First Operational Status Report, in the form set forth in subchapter Appendix Exhibit 2 incorporated herein by reference, demonstrating that they will be capable of implementing the timetable established in (a) above or will be requesting an extension of time pursuant to N.J.A.C. 11:22-3.5.
    3. On or before (300 days after the effective date of these rules) health benefit payers shall file an Interim Operational Status Report in the form set forth in Appendix Exhibit 2 in which the payer shall report that:

    1. It expects to comply with the timetable established by this subchapter; or
    2. It encountered unexpected delays and may not comply with the timetable. In such circumstances, the payer shall:

(1) Explain the cause of the delay;

(2) Provide an estimate of when compliance will be achieved; and

(3) Explain why the delay was not anticipated when the First Operational Status Report was filed pursuant to (b) above.

d. On or before (12 months after the effective date of these rules), all health benefit payers shall file the Final Operational Status Report in the form set forth in Appendix Exhibit 2, which certifies the then current status of the payer's system for electronic receipt and transmission of standard health care claims and enrollment forms pursuant to (a) above.

e. If, at the time the Final Operational Status Report is filed, a payer is not able to certify that it has a functioning system for the electronic receipt and transmission of health care claim information in accordance with N.J.S.A. 17B30-23, the payer shall file the required report together with supporting documents stating:

1. When compliance will be achieved; and

2. The reason(s) for the failure to comply.

f. When those payers described in (e) above achieve compliance, a Final Operational Status Report shall be filed within seven days of achieving compliance.

g. All reports described above shall in this section shall be filed at:

Department of Banking and Insurance
Attention: HINT/HIPAA Compliance
P.O. Box 325
20 West State Street
Trenton, NJ 08625-0325

11:22-3.5 Extensions of time and exemptions from compliance

  1. Health benefit payers may petition the Commissioner for an extension of the time limits set forth in N.J.A.C. 11:22-3.4 and/or to seek a waiver of the obligation to comply with the Act at any time after the filing of the First Operational Status Report filed in accordance with N.J.A.C. 11:32-3.4(a), but in no case later than the Interim Operational Status Report required to be filed by N.J.A.C. 11:22-3.4(b).

  2. Health benefit payers seeking an extension and/or exemption shall demonstrate that compliance with the timetable or these requirements will result in an undue hardship to the health benefit payer, a provider or a covered person.

  3. Small employer health benefit plans shall upon application and approval by the Department, be granted an additional six months for compliance with the provisions of N.J.A.C. 11:22-3.4 above. To qualify, the group plan must have less than 50 participants and/or less than $5 million in annual gross receipts.

11:22-3.6 Health care providers; claims

(a) On or after (12 months after the effective date of these rules) all payers shall require that all providers file all claims for payment unless, at the patient’s option, the patient elects to file the claim directly with the payer.

(b) Where a claim is being filed by the health care provider on behalf of the patient without an assignment of benefits, the provider shall file the claim within 60 days of the last date of service of that course of treatment.

(c) Where the provider is filing a claim under an assignment of benefits from the patient, the provider shall file the claim within 180 days of the last date of service of the course of treatment.

(d) In the event a health care provider does not file the claim within 180 days of the last date of service of a course of treatment referred to in (c) above, the third party payer and/or health benefit payer shall, within three days of the filing of the claim, reserve the right to deny payment of the claim in accordance with these rules and the health care provider shall be prohibited from seeking payment in whole or in part directly from the patient.

    1. When a health benefit payer reserves the right to deny payment of a claim in accordance with (d) above, the health benefit payer shall advise the health care provider that payment of the claim, in whole or in part, will be made based upon consideration of the following factors that shall be addressed by the provider:

      1. The good faith use of information provided by the patient to the health care provider with respect to the identity of the patient’s health benefits payer;

      2. Delays encountered in filing a claim related to the coordination of benefits among third party payers;

      3. Whether the health care provider has previously filed untimely claims or has an established pattern of untimely claim practices;

      4. Any prejudice to the rights of the patient and/or the health benefits provider in determination of the medical necessity of the services and care being billed for; and

      5. Potential adverse impact to the public.

(f) Providers failing to file a claim within 180 days in accordance with (d) above whose claim for payment has been denied in whole or in part may, in the discretion of a Judge of the Superior Court, be permitted to refile the claim where there has not been substantial prejudice to the health benefit payer. Application to the Superior Court for permission to refile a claim shall be made within 14 days of the notification of denial of payment and shall be made upon motion based upon affidavit(s) showing sufficient reason(s) for the failure to file the claim with the third party payer within the required time.

11:22-3.7 Additional timetables

    1. On or before (12 months after the effective date of these rules) all payers shall file with the Department a plan for the sequential implementation of usage of the following standard transactions, code sets and forms described below:

1. 45 CFR 162.1201, Subpart L - Eligibility for a Health Plan;

2. 45 CFR 162.1301, Subpart M - Referral Certification and Authorization;

3. 45 CFR 162.1401, Subpart N - Health Care Claim Status;

4. 45 CFR 162.1601, Subpart P - Health Care Payment and Remittance Advice;

5. 45 CFR 162.1701, Subpart Q - Health Plan Premium Payments;

6. 45 CFR 162.1801, Subpart R - Coordination of Benefits; and

7. 277 Transactions, ANSI ASC X12.317, Version 003070, Release 7, Sub-release O, October 1996, Electronic Health Care Claim Status Notification.

b. The plan referred to in (a) shall provide for full implementation of a system for the use of those electronic transaction and code sets referred to therein no later than October 16, 2002.

11:22-3.8 Use of clearinghouses in electronic transactions

(a) When computing the number of days for purposes of acknowledging an electronic claim and/or any other electronic exchanges required by this subchapter, the following shall apply:

1. When the provider chooses to use a clearinghouse for the transmission of claims to a payer, notice delivered by the payer to the clearinghouse shall constitute notice to the provider.

2. When a payer uses a clearinghouse for the receipt of any electronic transactions required by this subchapter, notice sent by the payer through the clearinghouse shall not constitute notice to a provider until it is delivered to the provider by the clearinghouse, or is available for pickup from the provider’s mailbox at the clearinghouse.

3. When a payer and provider use the same clearinghouse for the transmission and receipt of electronic transactions, notice that is sent by one party to the clearinghouse shall also constitute notice to the other party.

11:22-3.9 Information protection practices

All information and materials coming into the possession of health benefits payers, health care providers and their agents and vendors for the administration of the health care transactions described in this subchapter are subject to and shall comply with practices and requirements established in N.J.S.A. 17:23A-1 et seq.,the Insurance Information Practices Act.

11:22-3.10 Fraud prevention and detection

(a) All payers shall deploy as part of any system for the electronic receipt and transmission of claims an anti-fraud program, resident system and/or software that is approved by the Department’s Division of Anti-Fraud Compliance.

(b) The anti-fraud system described in (a) above shall be capable, at a minimum, of the following activities:

1. Screening all incoming claims data patterns associated with fraudulent activity;

2. Responding to audit specific inquiries to facilitate fraud investigations;

3. Identifying phantom vendors, employees, patients and providers;

4. Identifying inappropriate or inconsistent charges based on diagnosis codes; and

5. Scanning vendor claims for unnecessary and repetitive charges.

(c) The anti-fraud efforts described in this section shall be made a part of and incorporated into a payer’s fraud prevention and detection plan when required pursuant to N.J.A.C. 11:16-6, as applicable.

(d) Those payers not required to have a fraud prevention and detection plan under N.J.A.C. 11:16-6 shall file a description of the system required by this section with:

New Jersey Department of Banking and Insurance

Division of Anti-Fraud Compliance

Attn: HINT/HIPAA-Fraud Prevention and Detection Plans

P.O. Box 324

20 West State Street

Trenton, NJ 08625-0324

(e) Payers shall comply with the requirements of N.J.S.A. 17:33A-1 et. seq. regarding the obligation to report suspected fraud to the New Jersey Office of Insurance Fraud Prosecutor.

11:22-3.11 Penalties

Failure to comply with this subchapter may result in the imposition of penalties as authorized by law, including suspension or revocation of the payer’s authority to do business in the State of New Jersey.

 

APPENDIX

Exhibit 1

[Carrier]

GROUP ENROLLMENT [AND CHANGE FORM] [AND PRE-EXISTING CONDITIONS STATEMENT]

Please print all information, using ink.

[Policyholder] (full legal name of company): __________________________ (Policy) No: ____________

[Policyholder] Address: __________________________________________________________________

Street City State Zip Code

SECTION I: EMPLOYEE INFORMATION

Name: _________________________________________________

Last First Middle Initial

Home Address: _______________________________________________________________________

Street [Apt.] City [County] State Zip Code

[Telephone: ________________________ ________________________

Home Work

Best place to call during day: _____ Home _____ Work]

Occupation: _____________________________________ Title: ________________________________

Date of Employment: ______________________________ Hours worked per week: _________________

Are you actively at work? _____ Yes _____ No If "No", explain: _______________________________

Marital Status: _____ Single _____ Married _____ Widowed _____ Divorced

[Are you a resident of the state of New Jersey? _____ Yes _____ No

Do you maintain a residency in another state? _____ Yes _____ No

If "Yes", name the state ______________________________

How much time do you spend there each year? _____________]

[REASON FOR COMPLETION OF THIS FORM (please check all appropriate responses)

____ I am an employee of an organization which is applying for coverage

____ I am now eligible for coverage

____ I had no previous coverage during the past [90, 63] days

____ I had previous coverage during the past [90, 63] days.

Name of previous carrier ___________________ Plan Number: ___________

Effective Date: ______________________ Termination Date: ______________________

____ I previously refused/waived coverage

____ I am enrolling for coverage during my employer’s open enrollment period.

Open Enrollment Date: _____________

____ I am continuing under ______ Federal Law (COBRA) or ______ State Law

Qualifying Event: ____________________ Date Continuation began: ________________

Continuation applies to: _____ Employee Only _____ Employee and Eligible Dependents

____ I am continuing under a total disability extension (Attach proof of disability)

____ I am terminating coverage for myself, and all dependents

____ I am adding/deleting dependents

____ Other (Specify): __________________________________________________________________]

If you are declining enrollment for yourself or your dependents (including your spouse) because of other Group Health Plan coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within [30] days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within [30] days after the marriage, birth, adoption, or placement for adoption.

SECTION II: COVERAGE INFORMATION

1. Persons to be covered: _____ Employee Only _____ Employee & Child(ren)

_____ Employee & Spouse _____ Employee, Spouse & Child(ren)

2. Please provide all information for each person to be covered [or deleted].

Full Name (Last, First, Middle Initial) Add[/Delete] Sex Social Security No. Birthdate

Employee

Spouse

Child

Child

Child

Child

Attach a separate sheet to list additional children. [Attach proof if full-time student. Attach proof of disability.]

 

[3. Do any of the dependents listed above live at an address other than the Home address given above?

_____ Yes _____ No If "Yes", name the dependent(s) and provide the address(es) __________________________________________________________________________________________________________________________________________________________________________

Explain the circumstances _______________________________________________________________

4. If any dependent’s last name differs from yours, explain the circumstances _____________________________________________________________________________________]

[5] Indicate whether any person to be covered is enrolled under Medicare, Parts A and/or B.

Part A Part B Medicare ID #

Employee ___Yes___No ___Yes___No ____________

Spouse ___Yes___No ___Yes___No ____________

Child (give name)____________ ___Yes___No ___Yes___No ____________

[6] Which coverage have you selected to be primary in the event expenses are incurred as a result of an automobile related injury? _____ Auto _____ Medical

[7] Are you, or any person to be covered, eligible for other health coverage? (i.e., employer sponsored group coverage, Medicare, Medicaid).

_____ Yes _____ No If "Yes", indicate the name(s) of the person(s), the name(s) of the carrier(s), the policy number(s) and the type(s) of coverage. __________________________________________________________________________________________________________________________________________________________________________

[8] Are you replacing existing coverage? _____ Yes _____ No If "Yes", give the name and policy number of the replaced carrier, the effective and termination dates, and the names(s) of the persons covered by the policy. __________________________________________________________________________________________________________________________________________________________________________]

[9.] Were you, or any dependent(s) to be covered, covered under a prior Group Health Plan?

_____ Yes _____ No

If "Yes", attach the Certificate of Group Health Plan Coverage

Please note that if you do not provide the Certificate of Group Health Plan Coverage, you and any dependents to be covered, may be required to satisfy the pre-existing conditions limitation, if applicable.

[SECTION III: CHANGE INFORMATION

[Type of Activity

____ Termination of Employee and Dependent Coverage [Please check reason(s) below]

Date of Termination ______________________

____ Add/Remove Dependent

Reason________________________________________________________________________

Date of Event ______________________

____ New Telephone Number: (H) ________________________ (W) ________________________

____ Change Contract Type from ___________________________ to ___________________________

____ Change Name from ___________________________ to ___________________________

____ Change of PCP, GYN (Circle which, state for whom and give new name) ________________________________________________________________________________

____ Withdrawal from Coverage

Date of Event ___________________________

____ New Address: _____________________________________________________________________________________

Street [Apt.] City [County] State Zip Code]

[Termination Check Reason(s)

____ Deceased ____ Transferred to Other Coverage ____ Dissatisfied with Coverage

____ Ineligible ____ Moved Out of Area ____ Dissatisfied with Medical Care

____ Dissatisfied with Access

Other, please explain: ___________________________________________________________________

Remarks: ____________________________________________________________________________]]

[SECTION IV: PRE-EXISTING CONDITIONS STATEMENT

Note: This information may ONLY be used to determine if a condition is a pre-existing condition. You CANNOT be denied coverage under a health benefits plan on the basis of accurate responses to the following questions. Carriers can only use the information to expedite the processing of claims. However, benefits, services or supplies for the treatment of a pre-existing condition may be limited for [180, 365] days. This limitation of benefits, services and supplies does not apply to small employer groups with more than 5 employees. Consult the agent or carrier for information on the waiving of this limitation under circumstances as provided under New Jersey Law.

During the past 6 months have you, or any dependent to be covered had, or been diagnosed as having:

YES NO

1. a. Alcoholism or Drug Abuse _____ _____

b. Arthritis _____ _____

c. Blood Disorder _____ _____

d. Back or Neck Disorder, Injury or Pain _____ _____

e. Cancer or Tumors _____ _____

f. Diabetes _____ _____

g. Gastro or Intestinal Disorder _____ _____

h. Heart Disorder or Condition or Chest Pain _____ _____

i. High Blood Pressure _____ _____

j. Kidney or Liver Disorder _____ _____

k. Lung or Respiratory Disorder _____ _____

l. Mental or Nervous Disorder _____ _____

m. Paralysis, Stroke or Epilepsy _____ _____

2. During the past 6 months, have you or any dependent to be covered:

YES NO

a. been examined or treated by a physician or other health

care provider for any condition, illness or injury, other than as

stated above? _____ _____

b. been advised to have treatment or surgery or testing that

has not been done? _____ _____

c. been admitted to a hospital or other health care facility as

an inpatient? _____ _____

d. taken prescribed medications? _____ _____

Please give details of any "YES" answers to any parts of questions 1 or 2. Attach a separate sheet if more space is needed for answers. The separate sheet should be signed and dated.

Question Name Condition Duration of Symptoms, Date Name & Address Treatment, Degree of Recovery of Hospitals, Practitioners

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

[SECTION V: HEALTH CARE SELECTION

Full Name (Last, First, Middle Initial) [Primary Care Physician] [ [GYN]

Employee

Spouse

Child

Child

Child

Child

[NOTE: A Primary Care Physician must be selected for each adult member and a Pediatrician must be selected for each child. Women over the age of 16 must also select a GYN.]

[Plan Selection: _______________________________________________________________________]

SECTION VI: DECLARATION [AND] AUTHORIZATION [AND CONDITIONS OF ACCEPTANCE]

I hereby enroll for the group coverage to which I am or may be entitled. I authorize deductions from my pay for my share of the cost, if any.

I represent that to the best of my knowledge and belief, the statements and answers given above are true and complete. I understand that the information shall form the basis upon which I may be included for coverage under the group plan.

I understand that:

  1. the coverage applied for will not take effect unless:
  1. no person, except an officer of [Carrier] has authority to: determine whether [certificate/evidence of coverage] shall be issued based on this Enrollment Form; waive or modify any of the provisions of the Enrollment Form or any of the [Carrier’s] requirements; to bind [Carrier] by any statement or promise pertaining to any [certificate/evidence of coverage] to be issued on the basis of this Enrollment Form; or accept any information or representation not contained in the written Enrollment Form.
  2. the Employer is hereby designated my representative for the purpose of receiving contributions and remitting them to [Carrier].

[[Unless I request otherwise in writing,] I understand that by signing below when I file a claim, [Carrier] may pay the health care benefits directly to the provider instead of to me.]

[I state that I am a resident of New Jersey [and I live, reside or work within [Carrier’s] service area.]][I understand that if I omit or falsify any statement on this enrollment form, [Carrier] can cancel my coverage as of the original effective date.]

Any person who includes any false or misleading information on an application or enrollment form [and change form] for a health benefits plan is subject to criminal and civil penalties.

Note: A person who was covered under Creditable Coverage has a right to request a certificate from the prior plan or issuer to demonstrate that he or she was covered under Creditable Coverage. If necessary, [Carrier] will assist the person in obtaining a certificate from the prior plan or issuer.

[Conditions of Acceptance

On behalf of myself and the dependents listed on this Enrollment Form, I agree to or with the following:

  1. Employee is applying for coverage for the employee, employee’s spouse and any eligible unmarried children under [nineteen (19)] years of age, unmarried children who are mentally or physically incapacitated and who are chiefly dependent upon the employee or the employee’s spouse for support and maintenance or are unmarried children between the ages of [nineteen (19)] and [twenty-three (23)] who are enrolled as full-time students at an accredited school.
  2. Coverage and benefits are contingent on timely payment of premiums and may be terminated as provided in the Contract.
  3. The Contract will determine the rights and responsibilities of [covered persons] [members] [subscribers] and will govern in the event it conflicts with any benefits comparison, summary or other description of the health benefits plan.
  4. As a condition to [receiving in-network] benefits, employee understands and agrees that (with the exception of emergency procedures as defined in the Contract) all [in-network] services, in order to be covered by [Carrier], must be performed either by a participating primary care physician or by the participating specialist, hospital or other provider as authorized by prior written referral from the participating primary care physician. [Out-of-network benefits are covered, as stated in the contract.]
  5. Employee agrees to make payment directly to health care providers such copayments as are provided in the employer’s health benefits plan.
  6. Employee understands that this coverage will remain in effect regardless of the continued availability of a particular [primary care physician] [other health care provider].

Authorization

  1. I authorize the sources stated below to give to [Carrier], or any consumer reporting agency acting on its behalf, information about me and my minor children, if applying for coverage. Such information will pertain to employment, other health coverage, and medical advice, advice, treatment or supplies for any physical or mental condition. Authorizes sources are: any physician or medical professional; any hospital, clinic or other medical care institution; any carrier; any consumer reporting agency; any employer.
  2. I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which [Carrier] has taken in reliance on the authorization. I understand this authorization will not be valid after 30 months, if not revoked earlier.
  3. I know that I have a right to receive a copy of this authorization if I request one.
  4. I agree that a photocopy of this authorization is as valid as the original.

_________________________________ _________________________________________________

Date signed Signature of Employee

[_________________________________ _________________________________________________

Date signed Signature of Spouse, if providing information on the pre- existing conditions statement

_________________________________ _________________________________________________

Date signed Signature of Child who is 18 or older, if providing information on the pre-existing conditions statement]

 

 

 

 

 

 

 

 

 

EXHIBIT 2

 

 

New Jersey Department of

Banking and Insurance

ATTN: HINT Status Reports

20 West State Street

P.O. Box 325

Trenton, NJ 08625-0325

 

HINT Operational Status Report

  1. This is the:
  2. (Indicate one):

    ÿ First Report due on ________________________________.

    ÿ Interim Report due on ______________________________.

    ÿ Final Report due on ________________________________.

     

  3. The current status of the implementation of HINT electronic filing reports for health care benefit payment systems is:

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

 

3. If compliance is not yet achieved, indicate when the requirements of N.J.A.C. 11:22-3 will be accomplished:

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

 

 

 

4. What specific obstacles have been identified that may cause the filer NOT to comply with the timetable set forth in N.J.A.C. 11:22.

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

 

  1. Is the filer requesting an extension of time to comply with the timetable now or in the future?
  2. _________ No ________ Yes

    If yes, why: ________________________________________________

    __________________________________________________________

    __________________________________________________________

    __________________________________________________________

    __________________________________________________________

     

    6. Is the filer requesting a waiver from compliance with the HINT Electronic System request now or in the future?

    _________ No ________ Yes

    If yes, why: ________________________________________________

    __________________________________________________________

    __________________________________________________________

    __________________________________________________________

    __________________________________________________________

     

  3. Will the filer comply with the timetable for implementation of the additional transaction identified in N.J.A.C. 11:22-3.7?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

 

____________________ hereby certifies that the foregoing statements of fact are true and understand that he/she is subject to punishment for any intentional misstatements of fact.

 

 

 

 

 

____________________ __________________________

Date Name

 

 

__________________________

Agency

 

 

_________________________

Title of Signatory