17:48E-10. Agreements with service providers

a. A health service corporation may enter into agreements with providers of health care services whereby the providers become participating providers of health care services of that health service plan. Copies of agreements proposed to be entered into with participating physicians shall be filed with the commissioner. Every agreement shall provide: (1) for coverage of eligible health care services rendered to subscribers and covered dependents to the end of the subscription certificate year; (2) that 30 days' written notice of termination of the agreement may be given to the health service corporation at any time by any participating provider of health care services, but shall not apply to any subscription certificate in force at the time of notice until the first date thereafter when the subscription certificate may properly be terminated by the health service corporation; and (3) that the agreement of the provider of health care services to render services to the end of any certificate year shall not be affected by cessation of the transaction of business by the health service corporation. This requirement shall not apply to any subscription certificate which is not maintained in force by the payment of premiums required thereby.

b. A participating provider of health care services is one who agrees in writing to render health care services to or for persons covered by a contract or contracts issued by a health service corporation in return for which the health service corporation agrees to make payment directly to the participating provider. No person or facility shall become a participating provider of health care services unless he or it shall be legally authorized to provide health care services or supplies in this State. The board shall approve reimbursement rates paid to physicians.

c. A health service corporation may enter into agreements with other similar nonprofit health service corporations, hospital service corporations, or medical service corporations licensed under the laws of other states to provide for reciprocal payment of health care services to their respective subscribers and covered dependents rendered in the area served by the other corporation, provided that payments to participating physicians shall be at a rate not exceeding the same rate paid participating physicians under the certificate of the subscriber.

d. A health service corporation may establish criteria and standards for providers of health care services with which it desires to contract, and may establish its own contracting criteria for the providers as it shall determine, but contractual rates of payment to any hospital or health care facility shall be approved as to reasonableness by the Hospital Rate Setting Commission pursuant to section 18 of P.L. 1971, c. 136 (C.26:2H-18). The maximum rate of payment to eligible hospitals and institutions not under contract with the health service corporation shall not exceed those hospitals' or institutions' regular charges to the general public for the same services and shall be set forth in the certificate issued by the health service corporation to any subscriber. The basis and extent of payment, if any, by the health service corporation under agreements with nonprofit hospital service, medical service, or health service plans of other states shall be subject to the approval of the commissioner. e. Any dispute arising between a health service corporation and any provider of health care services with which the health service corporation has a contract for provision of health care services may be submitted to the commissioner for his determination with respect thereto, which determination shall be subject to review by the Superior Court in a proceeding in lieu of prerogative writ pursuant to section 43 of this act.

L. 1985, c. 236, s. 10, eff. July 15, 1985.