C.32 Out-of-Network Arbitration (OON)

N.J.S.A. 26:2SS-1 to -20 permits health care providers, carriers and, in certain instances, covered persons to apply for arbitration when they cannot agree on the appropriate reimbursement for health care services rendered by an out-of-network health care provider on an inadvertent , emergency or urgent basis.

1. The covered person to whom health care services were rendered was covered under a network-based health benefits plan that was issued by a carrier in New Jersey;
2. The health care service was rendered in New Jersey by a New Jersey licensed facility or practitioner;
3. The health care provider that rendered the health care services is not in the network of the covered person’s health benefits plan;
4. The covered person received out-of-network services from: (a) an out-of-network health care provider at an in-network health care facility on an inadvertent basis; (b) an out-of-network health care facility and/or practitioner on an emergency or urgent basis; or, (c) an out-of-network bio-analytical laboratory that performed a test that was ordered by an in-network health care provider and the covered person was not provided the opportunity to select an in-network bio-analytical laboratory; and
5. There is no dispute as to whether the health care services provided were Medically Necessary , cosmetic, experimental or investigational, or warranted an in-plan exception and the services are otherwise covered under the terms of the covered person’s health benefits plan.

This application for arbitration can be submitted by a health care provider, by the carrier (which, for purposes of this process includes the SHBP, the SEHBP, a MEWA, and any other payor providing a self-funded health benefits plan that opts into arbitration), or by a person covered by a self-funded health benefits plan in New Jersey that did not opt to participate in arbitration. However, a health benefits plan does not include coverage through Medicare or Medicaid.

Employers that self-fund may elect to use the OON Arbitration system. If a self-funded plan chooses to use the OON Arbitration System, the plan will be bound by the decision of the arbitrator. Persons covered by self-funded plans that do not opt into OON arbitration and the providers who treat such persons can still request OON arbitration but the arbitrator’s decision will not be binding on the self-funded plan and will not be based on the final offers of the provider and the self-funded plan. The arbitrator’s decision will be binding on the covered person and the provider.

If a health care provider needs to provide medical records to support a claim in arbitration, the health care provider must submit a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims. A covered person does not need to submit this form. The form is available at https://www.nj.gov/dobi/chap352/352consentform.doc.

The application and arbitration process is composed of two parts, and there is a separate fee for each part of the process. The Initial Review determines whether your request qualifies for actual arbitration based on the information submitted. If the request qualifies, then the matter will go to arbitration for a decision on the case. However, to complete your application, you must send fees for both the Initial Review and the Arbitration.

Send two checks (or money orders) made payable to MAXIMUS at the address above. The separate checks should be made for amounts consistent with the following:

1. Initial Review Fee -- $72.50 per case
2. Arbitration Fee -- $152.50 per case

Initial Review and Arbitration Review

After receiving the health care provider's completed application, MAXIMUS will contact the payer for a response, documentation, and payment of its portion of the fees. MAXIMUS will review the application and all documentation, and will contact the parties as to whether the request has been accepted for arbitration.

In some cases, MAXIMUS may need to request additional information from the party initiating arbitration, the responding party, or both. MAXIMUS will make such requests to the appropriate party in writing, and the party will have ten days to respond with the requested information in writing. Health care providers and Payers will have to send the requested information by regular mail, courier service, secure email or secure facsimile, to:

OON Bulletin

https://www.state.nj.us/dobi/bulletins/blt18_14.pdf

Other Issues

If dissatisfied with a claims determination, but the situation does not meet the requirements for a Chapter 32 Independent Arbitration, there are other processes available for health care providers or consumers to use. See https://www.nj.gov/dobi/division_insurance/managedcare/index.htm.

Questions

If you have any problems completing your application or you have questions regarding the arbitration process and other administrative matters, please contact MAXIMUS via email at njdobi@maximus.com, or by phone at (585) 348-3116. Please note that MAXIMUS will not accept verbal arguments for inclusion in the case record.