State RegulationsNJ specificDifficulty 2/5
A provider submits a paper claim to a New Jersey carrier, and the carrier believes the claim is not payable. What does the clean-claim denial-notice requirement demand?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
New Jersey's clean-claim framework requires a carrier to pay or deny a claim within the same fixed window that governs payment — 30 calendar days for electronic claims and 40 for paper claims — and notice of any denial or dispute must be given within that window. This requirement appears in N.J.S.A. 17B:30-13.1e and N.J.A.C. 11:22-1.6, and the New Jersey Department of Banking and Insurance enforces it. A carrier cannot escape the clock merely by planning to deny rather than pay.
Why the other options are wrong
- B) Year-end timing satisfies no part of the prompt-pay framework; the denial notice is due within the 30/40-day claim window.
- C) The 10-day figure is not the paper-claim deadline, and the framework does not allow an indefinite delay in explaining a denial.
- D) Silent holding is itself a violation; the rules require affirmative payment or notice of denial or dispute within the window.
Memory hook
Pay it or explain it — the denial rides the same 30/40-day clock.