The OMC also oversees the Independent Health Care Appeals Program (IHCAP). After a member or a provider, with the member’s consent, exhausts a carrier’s internal UM appeal process, the member or provider has a right to access the Stage 3 (external appeal) process through the IHCAP administered by the Department of Banking and Insurance (DOBI). DOBI contracts with independent utilization review organizations (IURO) to conduct the Stage 3 reviews for the IHCAP. The IURO’s determination is binding on the carrier. Provider complaints regarding carrier payment issues are also reviewed and investigated through DOBI’s Provider Prompt Payment Unit (PPPU) in the OMC. The PPPU also oversees DOBI’s Program for Independent Claims Payment Arbitration (PICPA).
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The Market Conduct Examinations Unit within the Office of Consumer Protection Services conducts on-site examinations of insurance company and agency operations and business practices to determine whether consumers, medical providers and other members of the public are being treated fairly and in accordance with New Jersey insurance laws. The unit examines life, health, managed care and property/casualty companies, with specialty lines reviewed as appropriate. For insurers that are subject to N.J.S.A. 17:33A, the New Jersey Insurance Fraud Prevention Act, and N.J.A.C. 11:16-6, {transact private passenger automobile or health insurance in this State} the on-site examination also will include review to determine compliance with fraud prevention, detection and reporting standards required by law.
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