N.J. Admin. Code § 11:24C-3.4 - Loss of designated status
(a) When a
designated health care provider with which the carrier has arranged for the
provision of services and supplies for the home treatment of bleeding episodes
associated with hemophilia loses designation, the carrier shall not continue to
refer covered persons to the services and supplies of that health care provider
for home treatment of bleeding episodes associated with hemophilia.
(b) With respect to covered persons that have
been receiving services and supplies from a health care provider that has lost
its designation, the carrier shall continue to provide services or benefits to
or on behalf of the covered person at an in-network level for home treatment
services and supplies, until such time as arrangements are made for the covered
person to receive home treatment services and supplies from another in-network
designated health care provider, or for four months following the date of the
loss of designation, whichever occurs first.
1. Notwithstanding (b) above, the carrier
shall not be required to continue to provide services or benefits to a covered
person at an in-network level when the health care provider's loss of
designation is the result of revocation or surrender of a license, permit or
registration, or is the result of a suspension of a license, permit or
registration that cannot be corrected by reinstatement within 45 days following
the date of the suspension, except as may be necessary for the carrier and
health care provider to transition the covered person's care to another
designated health care provider, consistent with
11:24C-2.1 1(a).
(c) Nothing in this subchapter
shall be construed to necessarily require termination of the agreement between
the carrier and health care provider, or otherwise affect the agreement to the
extent that it addresses the provision of services or supplies to covered
persons by the health care provider, or the performance of other functions
under the terms of the agreement, separate from those related to the home
treatment of bleeding episodes associated with hemophilia.
(d) Nothing in this section shall be
construed to require a carrier to provide more extensive benefits for covered
services than that which is specified in the underlying health benefits
plan.
Notes
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