NEW JERSEY

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The New Jersey SBL became effective August 30, 2018. N.J.S.A. 26:2SS-1 to -20. The relevant provisions of the New Jersey law are

• Reimbursement is to be at a “reasonable” amount.
• The initiating party must object to the payment and file the arbitration within 60 calendar days of the payment.
• UCR data can be submitted and often is the prevailing position in arbitration.

According to CMS,

New Jersey does not have an applicable All-Payer Model Agreement that would determine the out-of-network rate. Based on CMS communications with New Jersey Department of Banking and Insurance staff, CMS understands that N.J.S.A. 26:2SS-1 to -20 includes a specified state law that will apply for purposes of determining the out-of-network rate with respect to out-of-network services rendered on an inadvertent and/or emergency or urgent basis to individuals covered under a health benefits plan issued in New Jersey by a New Jersey licensed or certified health care provider.4 The federal independent dispute resolution process under section 2799A-1(c) of the PHS Act and 45 CFR 149.510 will apply for purposes of determining the out-of-network rate with respect to any items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in New Jersey by nonparticipating providers and nonparticipating emergency facilities to which N.J.S.A. 26:2SS-1 to -20 does not apply. The federal independent dispute resolution process under section 2799A-2(b) of the PHS Act and 45 CFR 149.520 will apply for purposes of determining the out-of-network rate with respect to any services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in New Jersey by nonparticipating providers of air ambulance services. New Jersey will seek voluntary compliance with the outcome of the federal independent dispute resolution process for such cases in New Jersey as laid out in the collaborative enforcement agreement mentioned above. If voluntary compliance is not reached, CMS will enforce the outcome of federal independent resolution process in New Jersey.

Letter from CMS to Governor of New Jersey, dated February 4, 2022.