Overview
New Jersey A.B. 5365 (2023) establishes prior authorization timelines and clinical rigor requirements. Standard requests must be decided within 4 business days; urgent requests within 48 hours. All denials require clinical rationale. The law promotes gold-carding for providers with consistently high approval rates. New Jersey Department of Banking and Insurance enforces compliance.
Key Requirements
| Request Type | Deadline | Special Rule |
|---|---|---|
| Standard prior auth | 4 business days | Gold-carding eligible |
| Urgent prior auth | 48 hours | Expedited review |
| Denial | Same timeframe | Clinical rationale required |
- Insurers must acknowledge prior authorization requests within 1 business day.
- Standard requests must be decided within 4 business days of receipt of a complete submission.
- Urgent requests must be decided within 48 hours of receipt.
- Providers with high approval rates qualify for gold-carding exemption.
- Denials must include specific clinical rationale and inform of appeal rights.
Penalties and Enforcement
New Jersey Department of Banking and Insurance enforces A.B. 5365 with fines for timeline violations. Failure to provide clinical rationale in denials may result in automatic approval. Plans with systematic violations face regulatory action and potential license restrictions. Gold-carding violations trigger enforcement action and consumer restitution.
Appeals and Exceptions
Denied prior authorization requests can be appealed within 30 days with additional clinical documentation. Expedited appeals are available for urgent requests. If the plan fails to provide clinical rationale, the prior authorization request may be deemed approved.
Interaction with Federal Law
New Jersey A.B. 5365 establishes state standards aligned with federal minimums. Federal ERISA rules require decisions within 30 days; New Jersey requires 4 business days. Clinical rationale and gold-carding requirements exceed federal standards.
Common Questions
What is the New Jersey prior authorization deadline?
4 business days for standard requests, 48 hours for urgent requests under New Jersey A.B. 5365 (2023).
Does New Jersey require clinical rationale in prior authorization denials?
Yes. All denials must include specific clinical rationale and inform providers of appeal rights under A.B. 5365.
Track New Jersey Prior Authorization Status
Altair monitors A.B. 5365 compliance, gold-carding eligibility, and clinical rationale requirements. See how it works.
State laws change. This reference is current as of 2026-04-06. Consult New Jersey A.B. 5365 or a healthcare attorney for definitive guidance.