N.J. Admin. Code § 11:24-3.5 - Provider contract termination

(a) The HMO shall establish a policy governing termination of health care professionals and other providers. The policy shall include at least:

1. Standards by which the HMO will provide notice to the provider of termination of his or her participation in the time and manner specified in the provider's contract.

i. In instances in which the contract is terminated prior to the contract's renewal date, the HMO shall provide health care professionals with at least 90-days written notice of the termination, specifying the health care professional's right to a hearing before a panel appointed by the HMO.

(1) The HMO shall provide in writing the reasons for the termination, if requested by the health care professional, within no more than 15 days of receipt of the request if the reason is not otherwise stated in the written notice of termination.

ii. HMOs shall not be required to provide 90-days prior written notice and the opportunity for a hearing for terminations of health care professionals based on: nonrenewal of the contract, a determination of fraud, breach of contract by the health care professional, or the opinion of the HMO's medical director that the health care professional represents an imminent danger to a patient or the public health, safety and welfare.

(1) An HMO that terminates a contract based on a determination of fraud shall report the fraud, with the basis for the determination of fraud, to the appropriate administrative agency (that is, the health care professional's licensing entity, such as the Board of Medical Examiners, the Board of Pharmacy, the Board of Chiropractic, and the Division of Criminal Justice).

(2) An HMO that terminates a contract based on a determination that the health care professional represents an imminent danger to the patient or the public health, safety and welfare shall report the determination to the appropriate State licensing board, and reports to the State Board of Medical Examiners shall be subject to N.J.S.A. 45:9-19.5.

2. Methods by which the termination policy shall be made known to providers upon initial participation and at the time of renewal of the provider's contract.

(b) HMOs shall provide written notification to each member at least 30 business days prior to the termination or withdrawal from the HMO's provider network of a member's PCP and any other physician or provider from which the member is currently receiving a course of treatment.

1. The 30-day prior notice to members may be waived in cases of immediate termination of a provider based on breach of contract by the provider, a determination of fraud, or where the HMO's medical director is of the opinion that the provider is an imminent danger to a patient or the public health, safety or welfare.

(c) The HMO shall assure continued coverage of covered services at the contract price by a terminated health care professional for up to four months in cases where it is medically necessary for the member to continue treatment with the terminated health care professional except as set forth below.

1. In cases of the pregnancy of a member, medical necessity shall be deemed to have been demonstrated and coverage of services by the terminated health care professional shall continue to the postpartum evaluation of the member, up to six weeks after delivery.

2. In the case of care post-operative care, coverage of services by the terminated health care professional shall continue for a period of up to six months.

3. In the case of oncological treatment, coverage of services by the terminated health care professional shall continue for a period up to one year.

4. In the case of psychiatric treatment, coverage of services by the terminated health care professional shall continue for a period of up to one year.

5. The HMO is not required to continue coverage for services obtained through a terminated health care professional in those instances in which the health care professional has been terminated based upon: the opinion of the HMO's medical director that the health care professional is an imminent danger to a patient or the public health, safety and welfare, a determination of fraud, or a breach of contract by the health care professional, or the health care professional is the subject of disciplinary action by the State Board of Medical Examiners.

6. The determination as to the medical necessity of a member's continued treatment with a terminated health care professional shall be subject to the appeal procedures set forth at N.J.A.C. 11:24-8.5 through 8.7.

(d) The HMO shall include in its agreements with providers, other than hospital providers, that, regardless of which party terminates the agreement, or the reasons for the termination, the HMO and the provider shall abide by the terms of the provider agreement, including reimbursement terms, for four months following the date of the termination, but the agreement may state that the provider has no obligation under the agreement to provide, and the HMO has no obligation to reimburse at the contracted rate, services which are not medically necessary to be provided by the provider on and after the 31st day following the date of termination.

(e) In the event that a hospital's contract is not renewed, or is terminated by either party, the hospital and the HMO shall continue to abide by the terms of the most current contract for a period of four months from a severance date mutually agreed upon by both parties as required by N.J.S.A. 26:2J-11.1. In such an event, the HMO shall provide written notification within the first 15 business days of the four month extension to all health care providers with which it has contracted and members who reside in the county in which the hospital is located or in an adjacent county within the HMO's service area. The notice to members shall also advise them of available options with respect to their health care coverage.

Notes

N.J. Admin. Code § 11:24-3.5

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
Rewrote the section.