The New Jersey Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act requires binding arbitration to resolve disputes between out-of-network providers and fully insured health benefit plans under New Jersey policies when the parties cannot agree on an appropriate claim amount.
The Act, which went into effect Aug. 30, 2018, covers those services a member receives from New Jersey providers, including doctors, hospitals, ambulatory surgery centers and other health professionals that are not part of the member’s health plan network.
New Jersey providers cannot bill the member for anything other than applicable deductible, copayment or coinsurance amounts for “inadvertent out-of-network services.”
The Act does not apply where an individual makes a conscious choice to use an out-of-network provider.
The New Jersey law applies to plans insured under New Jersey group policies and requires binding arbitration to resolve claim disputes between out-of-network providers and fully insured health benefit plans.
Self-funded plans are not automatically included. UnitedHealthcare is working on a process for those self-funded customers who may choose to opt in. More information will be coming soon.
If the carrier and the provider cannot agree following negotiations, there is an arbitration process. The arbitrator can only accept one of the two parties’ final offers. Generally, the arbitrator’s fee is split. Each party pays its own arbitration expenses.