New Jersey Billing Rights

Additional State-Law Protections for Patients with State-Regulated Health Plans

Under New Jersey’s “Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act:

• Health care providers are prohibited from balance billing a covered person for inadvertent out-of-network services and/or out-of-network services provided on an emergency or urgent basis above the amount of the covered person’s liability for in-network cost-sharing (i.e. the covered person’s network level deductible, copayments, or coinsurance).
  • “Inadvertent out-of-network services,” means health care services that are: covered under a health benefits plan that provides a network; and are provided by an out-of-network health care provider in an in-network health care facility when in-network health care services are unavailable in that facility or are not made available to the covered person. “Inadvertent out-of-network services” also includes laboratory testing ordered by an in-network health care provider and performed by an out-of-network bio-analytical laboratory; and
  • “Emergency or Urgent basis” means all emergency and urgent care services.
• Out-of-network arbitration: The Act creates an arbitration process to resolve out-of-network billing disputes for inadvertent and/or emergency/urgent out-of-network services. More information about arbitration, and the process for initiating the arbitration process, can be found at the Department’s arbitration vendor’s website at dispute.maximus.com/nj/indexNJ.
• Self-funded plans that opt in and providers – A self-funded plan may opt to be subject to the claims processing and arbitration provisions and be subject to the same arbitration process as carriers in the insured markets.
• Members of self-funded plans that do not opt in and providers – The process to initiate arbitration by members of self-funded plans that do not elect to the subject to this law (or “opt-in” to the law) is described at dispute.maximus.com/nj/OonFAQ.

Filing a Complaint

Any attempts by the out-of-network health care provider to bill the covered person for these types of services above the covered person’s in-network cost-sharing liability should be reported to the covered person’s carrier, and a complaint may be filed with the appropriate provider’s licensing board or other regulatory body, as appropriate.

A complaint may also be filed with the New Jersey Department of Banking & Insurance at www.nj.gov/dobi/consumer.htm. The Department will investigate the complaint and when appropriate, refer the matter to the appropriate licensing agency or regulatory body for review.

State Agency Contact Information

Department of Banking & Insurance

Phone: 800-446-7467
Website: www.nj.gov/dobi/consumer.htm

Additional Information

Visit www.cms.gov/nosurprises/consumers or call 800-985-3059 for more information about your rights under federal law.