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| Health Benefits Prompt Pay Rule - Information for Providers |
- Not all claims are subject to the Department of Banking and Insurance (DOBI) jurisdiction.
- Carriers must acknowledge receipt of claim. This can be electronically, in writing or by Web-based access.
- If you are a participating provider you should submit your internal payment appeal to the carrier in writing and provide the carrier with proof of claim receipt. Proof of receipt can be a fax receipt, electronic transmittal, certified mail receipts or a Web printout.
- If you disagree with the carrier's payment appeal determination, you have the right to an external independent review, or Alternate Dispute Resolution (ADR) per your participating provider contract.
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| Before filing a complaint with DOBI:
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- Send a letter of appeal to the carrier, it should clearly state that it is an internal appeal for a clean claim as provided by N.J.A.C .11:22-1.8. Carriers have ten business days after they receive a Prompt Payment appeal to issue a written determination.
- If the carrier's decision is adverse, request an external appeal (ADR). Information regarding the filing of an ADR should be contained in the letter of adverse determination provided by the carrier. The cost of the ADR is borne equally by the parties involved and is non-binding (unless agreed to otherwise by both parties).
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| To file a complaint with DOBI:
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- Send a letter or consumer complaint form clearly identifying areas of non-compliance with the regulation. Examples: the carrier did not provide method for ADR in written decision of internal appeal, a disproportionate number of "clean claims" are not paid within the 30-40 day timeframes, the carrier failed to respond to your written payment appeal within 10 business days.
- We need copies of the HCFA 1500, UB92 or dental form, including proof of receipt of the claim by the carrier. Proof of receipt can be a fax receipt, electronic transmittal, certified mail receipts or a web printout.
- You should include copies of your payment internal and external appeal and denial letters and any other relevant correspondence between you and the carrier.
- For non-participating providers, we require a letter from the insured authorizing our office to review the issue on their behalf. Alternatively, the insured can file a letter of complaint directly with the Office of Consumer Protection Services or through the online complaint form.
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Providers, please note that all the listed documentation is needed in order for DOBI to review your concerns.
This information can be mailed to:
Provider Prompt Pay Review
State of New Jersey
Department of Banking and Insurance
Office of Consumer Protection Services
PO Box 329
Trenton, NJ 08625-0329
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