N.J.S.A 17:48G-3 Dental decisions made by third party administrator.

17:48G-3 Dental decisions made by third party administrator.

3. a. A third party administrator may make dental decisions in connection with the processing or payment of dental claims or otherwise in the course of its dental benefit administration activity. Dental decisions made by a third party administrator shall be consistent with all of the following:

(1) an initial adverse dental decision shall be made by a dentist duly licensed in this or another state;

(2) if a treating dentist questions the adverse dental decision and specifies in writing the basis of the disagreement with the adverse dental decision, the third party administrator within 30 days shall:

(a) designate a reviewing dentist who is duly licensed in this State or who has been issued a limited registration certificate pursuant to section 4 of this act; and

(b) notify the treating dentist in writing promptly of the name and business address where the reviewing dentist can be contacted and telephone number which can be used to contact the reviewing dentist;

(3) if an agreement is not reached within a reasonable period of time, not to exceed 30 days from the third party administrator’s notice issued pursuant to subparagraph (b) of paragraph (2) of this subsection, the third party administrator shall make its decision and communicate the results of the reviewing dentist’s dental decision to the treating dentist.

b. Within 14 days of a written request by the treating dentist, or the patient or the patient’s authorized representative, for the basis of an adverse dental decision by a reviewing dentist, provided to the treating dentist pursuant to paragraph (3) of subsection a. of this section, the third party administrator shall send a written notice containing the full name, address and telephone number of the reviewing dentist and a narrative statement specifically identifying the basis for the decision.

L.2007, C. 259, S.3.


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