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:
- Administrative information;
- Diagnostic information;
- The status of the patient (voluntary or involuntary;
inpatient or outpatient);
- 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);
- A prognosis, limited to the estimated minimal time during
which treatment might continue.
- 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.
- 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:
- 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.
- 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.
- 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.
- 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.
- 1985, c. 256, s. 4.