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Finley

New Jersey Permanent Statutes

     TITLE 45  PROFESSIONS AND OCCUPATIONS

         45:14B-32. Disclosure to third-party payor


A patient who is receiving or has received treatment from a licensed,

practicing psychologist may be requested to authorize the

psychologist to disclose certain confidential information to a

third-party payor for the purpose of obtaining benefits from the

third-party payor for psychological services, if the disclosure is

pursuant to a valid authorization as described in section 6 of this

act and the information is limited to:

 

  1. Administrative information;

 

  1. Diagnostic information;

 

  1. The status of the patient (voluntary or involuntary;

inpatient or outpatient);

 

  1. The reason for continuing psychological services, limited to

an assessment of the patient’s current level of functioning and

level of distress (both described by the terms mild, moderate,

severe or extreme);

 

  1. A prognosis, limited to the estimated minimal time during

which treatment might continue.

 

  1. 1985, c. 256, s. 2.

 

If the third-party payor has reasonable cause to believe that the

psychological treatment in question may be neither usual, customary

nor reasonable, the third-party payor may request, and compensate

reasonably for, an independent review of the psychological treatment

by an independent professional review committee.  The request shall

be made in writing to the treating psychologist.  No third-party

payor having such reasonable cause shall terminate benefits without

following the procedures set forth in section 4 of this act.

 

  1. 1985, c. 256, s. 3.

 

Within 10 days of the receipt of the request for review by a

third-party payor, the treating psychologist shall notify the State

Board of Psychological Examiners of the request.  Pursuant to the

provisions of section 14 of this act, the State Board of

Psychological Examiners shall, within 10 days of the notification,

inform the treating psychologist of two or more members of the

independent professional review committee who shall be known as

“reviewers” and who shall conduct the review.  Under these

circumstances, the patient may, pursuant to a valid authorization as

described in section 6 of this act, authorize the treating

psychologist to disclose to the reviewers the requested confidential

information concerning his treatment.  This information shall be

disclosed only in accordance with the following procedure described

in this section and shall not be disclosed to a third-party payor or

any person other than the reviewers and shall not contain any

reference to the patient’s identification but rather shall refer to

an identification number assigned by the third-party payor.  If the

patient gives a valid written authorization, the reviewers shall,

pursuant to the following review procedure and within 20 days from

their receipt of the review request from the State Board of

Psychological Examiners, certify in writing to the third-party payor

whether or not in their opinion the treatment in question is usual,

customary or reasonable or if they are unable to make that

determination.  The treatment review shall take place as follows:

 

  1. The treating psychologist shall provide in writing to the

reviewers the following information:  the case identification

number; the status of the patient; duration and frequency of

treatment; the diagnosis; the prognosis; and the level of

functioning and the level of distress, both described by the terms

mild, moderate, severe or extreme.  If on the basis of this

information the reviewers can certify that the treatment is usual,

customary or reasonable, no further review shall be necessary at

that time.

 

  1. If the reviewers cannot make this determination from the

information provided, the reviewers shall request the treating

psychologist to provide a written statement describing his

customary mode of treatment for the particular diagnosis given.

If, on the basis of this information, the reviewers can certify

that the treatment is usual, customary or reasonable, no further

review shall be conducted at that time.

 

  1. If the reviewers cannot make this determination from the

information provided, they shall request the treating psychologist

to provide details and circumstances concerning the case under

review.  The reviewers shall then certify to the third-party payor

their conclusion as to whether or not the treatment in question is

usual, customary or reasonable, and the date and length of time of

the consultation.

 

  1. A negative conclusion by the reviewers pursuant to this

section shall not be used retroactively as a basis for denying

benefits for the treatment furnished prior to the review request

by the third-party payor, unless the claim for reimbursement

involves fraud or was not filed in a timely manner.

 

  1. 1985, c. 256, s. 4.

 

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