DOBI’s Proposed Appeal Rule DelayedMarch 29, 2016
A new rule was introduced to streamline the appeals process. Although a new APTP form has been adopted for use effective 4/15/2016, DOBI’s proposed uniform appeal rules, N.J.A.C. 11:3-4.7(c)6 and new rule N.J.A.C. 11:3-4.7B, have been delayed until November 5, 2016. We will continue to report on any updates.
DOBI’s notice can be found at:
Important: New Mandatory Uniform Attending Provider Treatment PlanMarch 28, 2016
As of April 15, 2016, all PIP providers will have to use a new Uniform Attending Provider Treatment Plan (APTP) form.
The APTP form can be found at:
It is important to not that that Box 35 is new and must be completed. Further, the failure to use the new APTP form will be subject to a 50% precertification penalty.
Auto Insurance Presentation Understanding Policy Limits and PIP Medical Expense BenefitsMarch 2, 2016
March 2, 2016
The River Palm Terrace
Keith Roberts Esq. presents the legal analysis for application of the “standard policy” $250,000.00 of PIP benefits, and the importance of the coverage selection form for all insureds.
Mr. Roberts, lecturing to a group of 100 doctors and lawyers, discusses the importance of understanding the importance of the New Jersey statutory requirement of a coverage selection form for automobile standard automobile insurance policy limits as per N.J.S.A 39:6A-4.3(e). Importantly, Roberts explains, that the applicable insurance regulations require that “lower limits” below that of the “standard” $250,000.00 of medical expense (PIP) benefits must be affirmatively selected in writing by the insured, as per N.J.A.C. 11:3-14.3.
In his presentation, Roberts relied upon the following authority:
Relevant No Fault Arbitration Awards:
Relevant Case Law:
Open MRI Rochelle Park v. Mercury 421 N.J. Super. 160 (App. Div. 2011)
Endo Surgery Center v. Liberty Mutual 391 N.J. Super. 588 (App. Div. 2007)
Weinsch v. Sawyer 123 N.J. 333 (1991)
Oravsky v. Encompass 804 F. Supp 2d 228
Statutes and Regulations:
Brach Eichler Filed Comments with DOBI Concerning Proposed Amendments to PIP Appeal RulesJanuary 4, 2016
Brach Eichler endorses the proposed amendments with the exception of pre-service appeals being applicable to secondary providers. Specifically, secondary providers, such as licensed ASCs, are not privy to pre-certification requests or subsequent denials from carriers concerning medical necessity. Therefore, these providers should not have a regulatory obligation to comply with the appeals process as it concerns medical treatment of insureds.
Further, Brach Eichler requested affirmation that the proposed amendment in no way conflicts with the statute of limitations set forth in N.J.S.A. 39:6A-13.1.
Click here to read the letter to DOBI.
PIP Update for ICD-10December 10, 2015
On October 1, 2015, the ICD-10 conversions began for medical providers, but it only applies to PIP in limited circumstances.
In summary providers should know:
• The ICD-10 conversion only applies to providers subject to Health Insurance Portability Accountability Act (HIPAA).
• Generally, PIP medical expense benefits are not subject to HIPAA.
• For the purposes of PIP medical expense reimbursement ICD-9 is still accepted unless the patient has elected for health insurance primary under his/her automobile policy.
• If the patient is health insurance primary, ICD-10 codes will need to first be billed to the employee health coverage, Medicaid or Medicare.
• Auto insurers accept either ICD-9 or ICD-10 billing
• DOBI will not be changing the Attending Provider Treatment Plan (APTP) to include ICD-10.
The DOBI post concerning ICD-10 is located at:
Contact Keith J. Roberts, Esq for additional information.
DOBI Proposes New Rules for PIP Claims Internal Appeal ProceduresNovember 4, 2015
The Department has proposed important amendments to the regulations that control the procedures for Medical Providers to file internal appeals for PIP claim denials.
The proposed new appeal rules will affect all insurance carriers and include the following important changes:
- The proposed amendment defines “pre-service” and “post-service” appeals.
- Insurance carriers may require one level appeals only.
- All carriers will be required to use a standardized appeal form.
- All pre-service appeals must be submitted within 30 days of the denial or modification of requested treatment.
- The carriers will have 14 days to reply to all pre-service appeals.
- All post-service appeals must be submitted 45 days prior to initiating dispute resolution.
- The carriers will have 30 days to reply to post-service appeal.
The proposed rules are an important development for medical providers as the internal appeals process will be streamlined, and simplified. It will be important, however, for providers to recognize the deadlines in the rules for filing appeals, as they are likely to be strictly enforced by Dispute Resolution Professionals.
You may submit any comments concerning the proposed rules to the Department by January 1, 2016 directly to email@example.com
Please direct further inquiry concerning this post to Keith J. Roberts, Esq.
DRP Rules That Failure of a Licensed ASC to Get Timely Facility "Accreditation" is Not a Basis For Carrier to Deny PaymentsOctober 13, 2015
Selective Insurance company denied facility fee payments to an ASC licensed by the NJ Department of Health (DOH) because it had not yet obtained "facility accreditation" as required by law. (N.J.S.A. 26:2H-12) The facts of the case are simple. A facility properly obtained ASC licensure from DOH and opened for business. The ASC later obtained Medicare certification, but was delayed in obtaining "facility accreditation" from an approved agency such as The Joint Commission or the Association for Ambulatory Health Care as required by law. The ASC provided services to Selective insureds during a period while facility "accreditation" was pending, although it was properly licensed. The ASC had applied for accreditation, but had not yet received it when the services were rendered to Selective insureds. The carrier denied payment arguing that the law required both "licensure" and "accreditation". Selective was successful in upholding the denial of payments based upon the ASC's lack of timely accreditation, and relied upon at least 5 favorable arbitration awards.
Brach Eichler was engaged by the ASC as special counsel to attack the issue. At oral hearing in a contested PIP arbitration, we argued the merits explaining that the DOH regulations must be read as a whole, and that accreditation can not serve as a bar to recovery for a licensed facility. The facts showed the ASC had obtained licensure from DOH and was Medicare certified. Additionally, the Department of Health renewed the ASC license while a facility accreditation application was pending, thereby allowing the center to operate lawfully. The DOH, not Selective Insurance Company, is the administrative agency with jurisdiction to make licensure determinations. The DRP agreed.
The ruling in the award is important in that it properly holds that the New Jersey Department of Health has controlling jurisdiction over ASC licensure issues, and where an ASC holds a valid license, it is eligible for PIP reimbursements. Click here to see award of the arbitrator.