N.J. Admin. Code § 11:22-3.3 - Standard enrollment/change request forms and application/change request forms

(a) 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.

(b) The UB-04, CMS 1450 (the uniform claim form for use by health care institutions and facilities) and the CMS-1500 (the uniform claim form for use by 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. Information concerning these forms is located at the website maintained by the Centers for Medicare and Medicaid Services (CMS), http://www.cms.gov and incorporated herein by reference.

(c) The paper standard formats for a universal enrollment/change request form and application/change request form for health insurance coverage can be accessed via the Department's website at http://www.state.nj.us/dobi/formlist.htm#insuranceformsandapps.

1. The enrollment/change request form requests or contains the following information:

i. The type of activity (for example, new enrollee/subscriber, a change in covered person(s), removal or termination of a covered person(s) or request for continuation of coverage);

ii. Employee information;

iii. Plan option;

iv. Individuals covered;

v. Pre-existing conditions statement;

vi. Other/previous insurance;

vii. Dependent information;

viii. Race/ethnicity (optional);

ix. Employee signature;

x. Employer verification;

xi. Instructions for completion of the form;

xii. A conditions of enrollment statement; and

xiii. A misrepresentation statement.

2. The application/change request form requests or contains the following information:

i. The type of activity (for example, new enrollee/subscriber, a change in covered person(s) or removal or termination of a covered person(s));

ii. Applicant information;

iii. Plan option;

iv. Individuals covered;

v. Pre-existing conditions statement;

vi. Previous insurance;

vii. Dependent information;

viii. Availability of other coverage;

ix. Race/ethnicity (optional);

x. Payment information;

xi. Applicant signature;

xii. Broker/general agent information;

xiii. Eligibility requirements;

xiv. Instructions for completion of the form;

xv. A conditions of enrollment statement; and

xvi. A misrepresentation statement.

(d) Subchapter Appendix Exhibit 3, incorporated herein by reference, is designated as the standard paper claim format to be used for all dental benefit claims.

(e) Payers may add a company name and logo to these standard paper forms.

Notes

N.J. Admin. Code § 11:22-3.3

Amended by R.2004 d.460, effective 12/20/2004.
See: 36 N.J.R. 1282(a), 36 N.J.R. 5913(a).
Rewrote (c).
Amended by R.2011 d.256, effective 10/17/2011.
See: 43 N.J.R. 1236(a), 43 N.J.R. 2668(b).
Rewrote (b) and the introductory paragraph of (c), and added (c)1 and (c)2.
Administrative correction.
See: 43 N.J.R. 3366(a).