Under the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act, which became effective on August 30, 2018, members who receive inadvertent and/or involuntary out-of-network services are protected by NJ state law.
In addition, the federal No Surprises Act, part of the Consolidated Appropriations Act of 2021, includes several provisions aimed to increase price transparency and patient protections against surprise medical billing (or balance billing).
An amendment to the NJ law went into effect October 28, 2022, that affects the submission time frames for requesting negotiation or arbitration, the state's mechanism for independent dispute resolution. Please keep in mind that the time frames for the NJ state law differ from the federal guidelines.
Claims that fall under these protections
Protected claims are those that are identified as inadvertent and/or involuntary out-of-network treatment. If the claim is identified as such, the patient responsibility is limited to the in-network cost-share.
Determining which law applies to your claim*
In New Jersey by a New Jersey-licensed provider†
| Claim is subject to the NJ state law
| Follow the instructions outlined on your Provider Explanation of
Benefits (EOB) to submit a request for negotiation.
| Submit a request for independent
dispute resolution.
|
Outside of New Jersey
| Claim is subject to the Federal law
| Submit an application to request an external arbitration.
|
If the claim is subject to the federal law and you do not submit your request for external arbitration within the allotted time, your claim does not become eligible for negotiation under the NJ state law.
*Claims for members in self-funded groups are subject to the federal law if the group has not elected to opt-in to the NJ state law.
†Exceptions apply for ground and air ambulance services, laboratory services, and certain places of service.
Comparison of negotiation and external dispute
Negotiation request deadline
| 30 business days post payment
| 60 calendar days post payment
|
Time period to negotiate
|
30 business days after initiation
| 60 calendar days that runs concurrently with the
initiation deadline
|
External dispute request deadline
| 4 business days after end of negotiation period
| 60 calendar days after final offer
|
Who conducts the external dispute
| Certified IDR chosen by agreement or randomly
| Maximus Federal Services
|
More information
For information on the NJ state law, visit DOBI's website.
For more information on the NJ Arbitration process, visit the Maximus Federal Portal.