NJ S1029

Health insurers must annually report claims data to the Department of Banking and Insurance, including in-network/out-of-network claims, denial and appeal rates, prior authorization approvals/denials, and most frequently denied procedures by medical specialty.

Insurers denying at least 20 percent of claims without proper justification in a year must refund covered persons the full cost they paid for denied services as a penalty.

Every submitted claim must be reviewed by at least one medical director, and all denial notices must include the reviewing physician's personal denial rate and average claim review time.

Carriers must publicly disclose on their websites whether they use automated utilization management systems (including AI-based software) and how many claims those systems reviewed in the prior year.

The Department of Banking and Insurance gains authority to audit insurers' automated utilization management systems at any time, with the law taking effect 13 months after enactment.