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.
Proposed Rule attached: N.J.A.C. 11:3-4.2 and 4.9
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 firstname.lastname@example.org
Please direct further inquiry concerning this post to Keith J. Roberts, Esq.