State RegulationsNJ specificDifficulty 3/5
A provider submits a health claim to a New Jersey carrier, but the submission omits information the carrier materially needs in order to process it. How does this affect the prompt-pay clock?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
The prompt-pay deadlines of N.J.S.A. 26:2J-8.1d, implemented in N.J.A.C. 11:22-1.6, attach to clean claims — submissions that are complete and free of defect or imprecision. A claim missing material information is not a clean claim, so the fixed 30-day electronic and 40-day paper windows do not key to it in the same way; the carrier's path is to seek the needed information promptly rather than let an incomplete submission stand in for a clean one. The New Jersey Department of Banking and Insurance polices abuse of this distinction in market conduct.
Why the other options are wrong
- A) There is no permanent suspension tied to a provider complaint; the analysis turns on whether the submission is clean.
- B) No automatic doubling exists; the framework distinguishes clean from deficient claims rather than extending deadlines across the board.
- D) Carrier questioning does not stop the clock for a claim that is in fact complete; only a genuinely deficient submission falls outside the clean-claim window.
Memory hook
No clock without a clean claim — incompleteness freezes the deadline key.