N.J. Admin. Code § 11:24-8.8 - General requirements for independent utilization review organizations

(a) The Department shall, from time to time, enter into contracts with as many independent utilization review organizations as it deems necessary to conduct the external appeals provided for under N.J.A.C. 11:24-8.7. The physician reviewers of the IUROs selected by the Department shall be experienced in managed care utilization review. The contracts shall set forth all terms which the Department deems necessary to ensure a member's right of appeal under N.J.A.C. 11:24-8.7 including, but not limited to, an assessment of separate costs to the HMO for the initial IURO review under N.J.A.C. 11:24-8.7(e) and the full review under N.J.A.C. 11:24-8.7(g).

(b) As a part of the contract process set forth in (a) above, all IUROs shall submit to the Department and shall maintain current, a list identifying all HMOs, health insurers, health care facilities and other health care providers with whom the IURO maintains any health related business arrangements. This list shall include a brief description of the nature of any such arrangement.

(c) Upon receipt of any request for an external appeal under N.J.A.C. 11:24-8.7(d) above, the Department shall assign that appeal to one of the approved IUROs on a random basis. The Commissioner reserves the right to deny any assignment to any IURO if, in his or her determination, such an assignment would result in a conflict of interest or would otherwise create an appearance of impropriety. In reaching such a determination, the Commissioner shall take into consideration the list required of IUROs in (a) above.

(d) An IURO must have external review accreditation from a nationally recognized private accrediting organization, such as URAC.

Notes

N.J. Admin. Code § 11:24-8.8

Amended by R.2012 d.035, effective 2/6/2012.
See: 43 N.J.R. 2411(a), 44 N.J.R. 274(b).
Added (d).