{"data":{"id":"us-nj/n.j.-stat.-17b-30-55.12","jurisdiction":"us-nj","citation":"N.J. Stat. § 17B:30-55.12","heading":"Adverse determinations, appeal, reviewed by physician.","body":"13.  A payer shall ensure that any adverse determinations of any appeal are reviewed by a physician.  The physician shall:\na.\tbe board-certified in a same or similar specialty that has experience treating the condition or service under review or has experience treating the condition within the last five years;\nb.\tnot be paid by a payer based on the reviewing physician's denial or approval rate;\nc.\tnot have been directly involved in making an initial adverse determination for the same claim;\nd.\tconsider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the payer by the health care provider of the covered person, any relevant records provided to the payer by a health care facility, and any medical literature provided to the payer by the health care service provider of the covered person;\ne.\tnot be provided preferential treatment by the payer in the reviewing physician's own requests for prior authorization if the reviewing physician is also a network provider; and\nf.\twhen requested by the treating provider, engage in a telephonic conversation with the treating provider to discuss the need for the prescribed medication or service.\nL.2023, c.296, s.13.","path":["TITLE 17B INSURANCE"],"source_url":"https://pub.njleg.state.nj.us/statutes/STATUTES-TEXT.zip","current_through":"P.L.2025, c.405, and J.R.22","vintage":"","retrieved_at":"2026-08-27T17:54:13Z","sha256":"0cc413fa8a3f63c59850e67bba41f2dcbe28e08d641110b2492331f0ad117967","source_id":"us-nj","stale":true,"prev":"us-nj/n.j.-stat.-17b-30-55.11","next":"us-nj/n.j.-stat.-17b-30-55.13"},"notice":"GroundRules: Original legal text. Not legal advice."}