S 4692 — Establishes standards for timely payment of clean claims by pharmacy benefits managers.

Summary

Pharmacy benefits managers-estab standards for timely payment of clean claims

Bill Text

• Introduced View text Current html October 02, 2026

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This bill amends 1 section(s) of the New Jersey statutes: N.J.S.A. 17B:27F-7.

• N.J.S.A. 17B:27F-7

  benefit → A claim shall also be considered a clean claim if a pharmacy benefits manager does not provide notice to the submitting pharmacy of any defect or impropriety in a claim pursuant to subsection f. of this section within: (1) 10 days of receipt of a claim submitted electronically; or (2) 15 days of receipt of a claim submitted on paper. benefits e. A pharmacy benefits manager shall issue, mail, or otherwise transmit payment with respect to a clean claim submitted by a pharmacy within: (1) seven to 14 days after the date of the receipt of a claim submitted electronically; or (2) 30 days after the receipt of a claim submitted on paper. f. (1) If a pharmacy benefits manager determines that a claim submitted by a pharmacy is not a clean claim, the pharmacy benefits manager shall notify the submitting pharmacy of the determination within the periods provided for in subsection b. of this section. A notification provided to a pharmacy pursuant to this subsection shall: (a) be submitted in writing or electronically to the pharmacy; (b) specify all defects or improprieties in the claim; and (c) list any additional information necessary for the proper processing and payment of the claim. (2) After a pharmacy submits to the pharmacy benefits manager any additional information necessary for the proper processing and payment of the claim, a claim shall become a clean claim within 10 days if the pharmacy benefits manager does not provide notice to the submitting pharmacy of any remaining defect or impropriety in the claim or of any new defect or impropriety in the additional information submitted. (3) A pharmacy benefits manager shall not provide a pharmacy notice of a new deficiency or impropriety in a claim that could have been identified by the pharmacy benefits manager in the original claim submitted by a pharmacy. g. A claim submitted to a pharmacy benefits manager that is not paid by the pharmacy benefits manager within the periods provided for in subsection e. of this section or contested by the pharmacy benefits manager pursuant to subsection f. of this section shall be: (1) deemed to be a clean claim; and (2) paid by the pharmacy benefits manager to a pharmacy pursuant to subsection e. of this section. h. A payment of a clean claim pursuant to paragraph (1) of subsection g. of this section is considered to have been made on the date that: (1) the payment is transferred, for a claim submitted electronically; or (2) the payment is submitted to the United States Postal Service or common carrier for delivery, for any other claim. i. (1) A pharmacy benefits manager shall, for a late payment of a claim to a pharmacy, pay a penalty equal to 12 percent of the late payment per month starting on the day after the required payment date and ending on the day the proper payment for the claim is made. (2) A pharmacy benefits manager shall not be penalized or required to pay interest under this subsection in exigent circumstances that prevent the timely processing of claims, including natural disasters and other unique and unexpected events, unless the circumstances involve a cybersecurity breach or a data security issue with the pharmacy benefits manager. A cybersecurity breach or a data security issue involving the pharmacy benefits manager that delays payment to a pharmacy is subject to interest payments under this subsection. j. A pharmacy benefits manager shall pay a clean claim submitted electronically by an electronic transfer of funds if the submitting pharmacy requests that the payment be made by an electronic transfer of funds or has requested that a payment be made by an electronic transfer of funds in that contract year. If a payment is made electronically, remittance may also be made electronically by the pharmacy benefits manager. k. (1) Nothing in this section shall be construed to prohibit or limit a claim or action not covered by this section that an individual or organization has against a pharmacy, healthcare provider, or pharmacy

  amended

Action History

1. October 01, 2026

   INT 1RS REF SCM

Sponsors

• Douglas J. Steinhardt · Primary
• Vin Gopal · Primary
• Angela V. McKnight · Cosponsor

Subjects