NJ  CAR  INSURANCE  PIP  PERSONAL  INJURY  PROTECTION  OVERVIEW  

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NJ  Car  Insurance-­‐  NJ  Auto  Insurance  Policy  Under  A.I.C.R.A.,  New  Jersey  consumers  have  more  choices  with  regard  to  their  NJ  Car  Insurance.  These  choices  give  you  the  option  to  choose  coverage  limits  that  best  fit  your  individual  needs  at  the  time  you  buy  or  renew  your  policy.    

New  Jersey  CAR  INSURANCE  -­‐  BASIC  POLICY  New  Jersey  Car  Insurance  Consumers  may  choose  either  a  standard  auto  insurance  policy  or  a  new  basic  type  of  policy.  The  new  basic  policy  allows  vehicle  owners  to  purchase  lower  amounts  of  certain  coverage's  than  New  Jersey  law  previously  required.    

A  basic  policy  offers  $15,000  in  PIP  personal  injury  protection  coverage  and  includes  up  to  $250,000  of  medical  benefits  coverage  for  catastrophic-­‐type  injuries,  $5,000  property  damage  liability  and  an  option  to  purchase  $10,000  of  bodily  injury  liability  coverage.  If  you  purchase  a  basic  policy,  you  cannot  purchase  uninsured/underinsured  motorist  coverage.  Companies  can,  at  their  option,  also  offer  to  sell  collision  and  comprehensive  coverage's  with  this  type  of  policy.    

NJ  CAR  INSURANCE  -­‐  STANDARD  POLICY  A  New  Jersey  standard  auto  insurance  policy  offers  motorists  a  variety  of  coverage  options;  NJ  State  law  requires  you  to  purchase  certain  minimum  limits  of  three  coverage's:    

NJ  CAR  INSURANCE  POLICY  Personal  Injury  Protection  -­‐NJ  PIP  pays  for  injuries  to  you  and  your  passengers,  no  matter  who  is  at  fault  in  an  accident.  Insurance  companies  must  offer  you  up  to  $250,000  of  coverage.  

NJ  CAR  INSURANCE  POLICY  Liability  Coverages  -­‐  Bodily  Injury  Liability  pays  for  injuries  you  cause  to  others  in  an  accident.  Under  a  standard  policy  the  minimum  coverage  required  is  $15,000  for  injuries  to  one  person  and  $30,000  for  all  injuries  in  an  accident.  Property  Damage  Liability  pays  for  damage  you  cause  to  others'  property  from  an  accident.  The  minimum  required  coverage  is  $5,000.  

   

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NJ  CAR  INSURANCE  POLICY  Uninsured/Underinsured  Motorist  -­‐  These  coverage's  protect  you  against  damages  and  injuries  caused  by  drivers  who  are  uninsured  or  inadequately  insured.  These  coverages  are  not  available  under  a  basic  policy.  Minimum  limits  are  the  same  as  for  the  liability  coverage's  and  the  basic  deductible  is  $500  for  property  damage.    NJ  CAR  INSURANCE  POLICY  Optional  Coverage's  Collision  coverage  pays  to  repair  your  car  after  an  accident,  no  matter  who  is  at  fault.  Comprehensive  coverage  pays  for  auto  theft,  glass  breakage  and  damage  from  vandalism,  fire,  flood  and  flying  rocks  and  debris.    

NJ  CAR  INSURANCE-­‐  PIP  OPTIONS  NJ  CAR  INSURANCE  Consumers  will  also  have  new  choices  with  regard  to  their  personal  injury  protection  or  PIP  benefits  coverage.  New  Jersey  law  previously  mandated  that  all  policyholders  purchase  $250,000  of  PIP  benefits.  PIP  pays  for  injuries  to  you  and  your  passengers,  no  matter  who  is  at  fault  in  an  accident.    

Under  the  AICRA  reform  law,  individuals  purchasing  a  'standard'  policy  have  the  option  of  choosing  various  levels  of  coverage,  $250,000,  $150,000,  $75,000,  $50,000  or  $15,000.  All  the  options  include  catastrophic-­‐type  injury  coverage  of  up  to  $250,000.  If  you  do  not  choose  among  these  options,  you  will  automatically  be  given  the  standard  $250,000    The  reform  law  also  encouraged  insurance  companies  to  develop  various  deductible,  co-­‐payment  and  pre-­‐certification  plans  to  combat  fraud  and  abuse  of  auto  insurance  medical  benefits.  Consumers  should  carefully  review  these  plans.        NJ  Auto  Insurance  PIP  Overview    "PIP"  is  an  acronym  for  the  PERSONAL  INJURY  PROTECTION  BENEFITS  contained  within  an  NJ  automobile  insurance  policy.        With  the  enactment  of  the  AUTOMOBILE  INSURANCE  COST  REDUCTION  ACT  ("AICRA")  ,  NJ  medical  providers  were  imposed  with  a  complete  new  set  of  rules  to  follow  in  order  to  obtain  compensation  for  

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reasonable  and  necessary  medical  expenses  rendered  to  a  covered  person  when  the  medical  expenses  were  causally  related  to  a  motor  vehicle  accident.    Failure  to  comply  completely  with  the  new  set  of  rules  would  result  in  the  reduction  and/or  elimination  of  compensation  due  the  medical  provider  from  the  respective  automobile  insurance  carrier.    Furthermore,  failure  to  comply  completely  with  the  new  set  of  rules  would  also  result  in  the  medical  provider  being  prohibited  from  collecting  the  compensation  due  directly  from  the  patient.    Given  the  above,  it  is  obvious  that  the  medical  provider  and  the  supporting  office  staff  must  have  complete  familiarity  with  the  new  set  of  rules  and  terminology  ushered  in  with  AICRA.    If  this  complete  familiarity  is  accomplished,  the  medical  provider  will  still  be  able  to  enjoy  the  financial  rewards  of  a  successful  practice  with  PIP.      However,  if  the  medical  provider  and  the  supporting  office  staff  fails  to  become  completely  familiar  with  the  new  set  of  rules  and  terminology  ushered  in  with  AICRA,  financial  detriments  will  certainly  occur.    Prior  to  AICRA,  the  treating  medical  provider  basically  controlled  the  treatment  plan  of  the  patient  and  the  diagnostic  testing  utilized  in  the  furtherance  of  the  treatment  plan  of  the  patient.    However,  AICRA  has  now  delegated  the  COMMISSIONER  of  the  DEPARTMENT  OF  BANKING  AND  INSURANCE  ("DOBI")  to  be  an  important  factor  in  the  aforementioned  treatment  plan  of  the  patient  and  the  diagnostic  testing  utilized  in  the  furthermore  of  the  treatment  plan  of  the  patient.    This  was  accomplished  by  the  passing  of  regulations  by  NJDOBI  that  established  and/or  continued  the  following:  

• APPLICABILITY  OF  PIP  MEDICAL  BENEFITS;  • STATUTORY  EXCLUSIONS  OF  PIP  MEDICAL  BENEFITS;  • BASIC  POLICY  PIP  MEDICAL  BENEFITS;  • STANDARD  POLICY  PIP  MEDICAL  BENEFITS;  • PRIMARY  HEALTH  INSURANCE  OPTION;  • DEDUCTIBLE  AND  CO-­‐PAYMENT  REQUIREMENTS;  • PIP  FEE  SCHEDULE;  • MEDICAL  PROTOCOLS  (CARE  PATHS);  • DIAGNOSTIC  TESTING  DETERMINED  TO  YIELD  NO  DATA  OF  ANY  SIGNIFICANT  VALUE  IN  THE  DEVELOPMENT,  EVALUATION  AND  IMPLEMENTATION  OF  AN  APPROPRIATE  PLAN  OF  TREATMENT  

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FOR  INJURIES  SUSTAINED  IN  MOTOR  VEHICLE  ACCIDENTS;  • DIAGNOSTIC  TESTING  DETERMINED  TO  HAVE  VALUE  IN  THE  EVALUATION  OF  INJURIES,  THE  DIAGNOSIS  AND  DEVELOPMENT  OF  A  TREATMENT  PLAN  FOR  PERSONS  INJURED  IN  MOTOR  VEHICLE  ACCIDENTS;  

• TWENTY  ONE  DAY  NOTIFICATION  UPON  COMMENCEMENT  OF  TREATMENT;  

• DECISION  POINT  REVIEW  PLAN;  • PRIOR  NOTICE;  • DECISION  POINTS;  • CASE  MANAGEMENT;  • ADDITIONAL  CO-­‐PAYMENT  PENALTY;  • TEN  DAY  PERIOD;  • ADDITIONAL  CO-­‐PAYMENT  PENALTY;  • PRE-­‐CERTIFICATION  PLAN;  • COMPENSATION  FOR  DURABLE  MEDICAL  GOODS;  • PIP  DISPUTE  RESOLUTION  (FORMERLY  "PIP  ARBITRATION");  • DISPUTE  RESOLUTION  PROFESSIONAL  ("DRP"  AND  FORMERLY  "PIP  ARBITRATOR");  

• ASSIGNMENT  OF  BENEFITS;  • MEDICAL  REVIEW  ORGANIZATION  REVIEW;  • APPLICATION  FOR  DISMISSAL  and  • EMERGENT/EXPEDITED  FILING.  

APPLICABILITY  OF  PIP  MEDICAL  BENEFITS    A  person  is  eligible  for  PIP  medical  benefits  pursuant  to  N.J.S.  39:6A-­‐4  if  that  person  sustains  "bodily  injury  as  a  result  of  an  accident  while  occupying,  entering  into,  alighting  from  or  using  an  automobile,  or  as  a  pedestrian,  caused  by  an  automobile  or  by  an  object  propelled  by  or  from  an  automobile,  to  other  persons  sustaining  bodily  injury  while  occupying,  entering  into,  alighting  from  or  using  the  automobile  of  the  named  insured,  with  permission  of  the  named  insured,  and  to  pedestrians  sustaining  bodily  injury  caused  by  the  named  insured's  automobile  or  struck  by  an  automobile  or  struck  by  an  object  propelled  by  or  from  that  automobile.    As  before  AICRA,  the  payment  of  PIP  medical  benefits  is  made  

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without  regard  to  negligence,  liability  or  fault  and  covers  the  named  insured  and  family  members  that  reside  with  the  named  insured.    If  the  person  is  not  a  named  insured  and  does  not  reside  with  a  family  member  that  is  a  named  insured,  then  the  coverage  follows  the  automobile.  As  also  before  AICRA,  there  must  be  an  automobile  involved  as  put  forth  in  the  language  of  N.J.S.  39:6A-­‐4  above  for  applicability  of  PIP  medical  benefits.    TAXICABS,  BUSES  and  MOTORCYCLES  are  the  prime  examples  of  motorized  vehicles  that  are  not  considered  automobiles.    STATUTORY  EXCLUSIONS  OF  PIP  MEDICAL  BENEFITS    Once  the  applicability  of  PIP  medical  benefits  has  been  established,  there  are  still  certain  statutory  exclusions  that  can  eliminate  PIP  medical  benefits  due  to  the  actions  of  the  person.    These  statutory  exclusions  are  contained  in  N.J.S.  39:6A-­‐7  and  are  listed  below:  

COMMITTING  A  CRIMINAL  ACT  OR  ATTEMPTING  TO  AVOID  LAWFUL  APPREHENSION  BY  A  POLICE  OFFICER;  (N.J.S.  39:6A-­‐7(a)(1));  

COMMITTING  AN  INTENTIONAL  ACT  TO  CAUSE  INJURY  OR  DAMAGE  TO  ONESELF  OR  OTHERS;  

(N.J.S.  39:6A-­‐7(a)(2));  

OWNING  AN  UNINSURED  MOTOR  VEHICLE;  

(N.J.S.  39:6A-­‐7(b)(1));  

UTILIZING  A  MOTOR  VEHICLE  WITHOUT  OWNER'S  CONSENT;  (N.J.S.39:  6A-­‐7(b)(2)).  

NJ  AUTOMOBILE-­‐BASIC  POLICY  PIP  MEDICAL  BENEFITS    Assuming  that  there  is  no  statutory  exclusion  of  PIP  medical  benefits  as  outlined  above,  a  new  limitation  of  PIP  medical  benefits  was  ushered  in  under  AICRA  depending  upon  the  type  of  automobile  policy  that  is  chosen  by  the  insured.    Specifically,  if  an  insured  elected  the  BASIC  POLICY,  the  PIP  medical  benefits  are  limited  to  $15,000.00.  (N.J.A.C.11:  3-­‐4(a)(1)).    

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The  only  exception  would  be  additional  monetary  coverage  not  to  exceed  $250,000.00  for  "all  medically  necessary  treatment  of  permanent  or  significant  brain  injury,  spinal  cord  injury  or  disfigurement  or  medically  necessary  treatment  of  other  permanent  or  significant  injuries  rendered  at  a  trauma  center  or  acute  care  hospital  immediately  following  the  accident  and  until  the  patient  is  stable,  no  longer  requiring  critical  care  and  can  be  safely  discharged  or  transferred  to  another  facility  in  the  judgment  of  the  attending  physician.    (N.J.A.C.  11:3-­‐4(a)(1)).    STANDARD  POLICY  PIP  MEDICAL  BENEFITS    If  the  BASIC  POLICY  was  not  elected,  then  the  monetary  coverage  that  was  applicable  prior  to  AICRA  remains  in  effect  and  the  insured  has  what  is  now  known  as  the  STANDARD  POLICY.    Specifically,  this  policy  provides  monetary  coverage  for  PIP  medical  benefits  to  an  amount  not  to  exceed  $250,000.00.  (N.J.S.  39:6A-­‐4(a)).    Notwithstanding  the  aforementioned  monetary  coverage  limits  of  PIP  medical  benefits  under  the  BASIC  or  STANDARD  POLICY,  the  type  of  treatment  and  type  of  diagnostic  testing  utilized  in  the  furtherance  of  the  treatment  plan  for  the  patient  have  been  altered  under  AICRA.    This  is  further  described  later  on  in  this  overview.    PRIMARY  HEALTH  INSURANCE  OPTION    As  before  AICRA,  a  PRIMARY  HEALTH  INSURANCE  OPTION  is  made  available  to  insured's  that  would  make  PIP  medical  benefits  under  an  automobile  insurance  policy  a  secondary  coverage  for  a  reduced  premium.  (N.J.S.  39:  6A-­‐4.3(d)).    However,  under  AICRA,  the  PRIMARY  HEALTH  INSURANCE  OPTION  applies  only  to  a  STANDARD  POLICY.    It  is  specifically  prohibited  as  a  coverage  option  under  a  BASIC  POLICY.  (N.J.A.C.  11:3-­‐4(d)).    However,  if  a  named  insured  does  not  actually  have  health  insurance  at  the  time  of  the  accident,  then  the  automobile  insurance  carrier  automatically  becomes  the  primary.    But,  an  additional  $750.00  deductible  is  applied  to  the  medical  benefit  payments.    (N.J.S.  39:6A-­‐4.3(f)).    

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In  addition  to  the  above,  it  must  be  noted  that  the  election  of  a  PRIMARY  HEALTH  INSURANCE  OPTION  applies  only  to  a  named  insured  and  residing  family  members.    As  such,  an  individual  who  is  not  a  named  insured  and  does  not  reside  with  a  family  member  who  is  a  named  insured  automatically  but  is  properly  applying  for  PIP  medical  benefits  under  the  policy  has  the  automobile  insurance  carrier  as  primary.  (N.J.S.  39:6A-­‐4.3(f)).    DEDUCTIBLE  AND  CO-­‐PAYMENT  REQUIREMENTS:    Prior  to  AICRA,  a  standard  $250.00  deductible  requirement  and  20%  co-­‐payment  requirement  on  the  next  $4750.00  in  medical  expenses  was  applied.    However,  under  AICRA,  deductibles  can  now  be  offered  to  insured's  under  a  BASIC  POLICY  or  a  STANDARD  POLICY  in  amounts  of  $500.00,  $1000.00,  $2000.00  and  $2500.00.  (N.J.A.C.  11:3-­‐4.4(b)).    The  only  exception  is  for  a  private  passenger  automobile  insured  under  a  commercial  automobile  insurance  policy  where  no  natural  person  is  a  named  insured.    In  that  situation,  only  the  minimum  $250.00  deductible  can  be  offered.  (N.J.A.C.  11:3-­‐4.4(e)).    Furthermore,  the  elected  deductible  requirement  applies  on  a  per  accident  basis,  not  a  per  person  basis.  (N.J.A.C.  11:3-­‐4.4(c)).    Notwithstanding  the  aforementioned,  it  must  be  noted  that  the  elected  deductible  applies  only  to  a  named  insured  and  residing  family  members.    As  such,  an  individual  who  is  not  a  named  insured  and  does  not  reside  with  a  family  member  who  is  a  named  insured  automatically  but  is  properly  applying  for  PIP  medical  benefits  under  the  policy  has  the  minimum  $250.00  deductible.  (N.J.A.C.  11:3-­‐4.4(b)(1)).  

 MEDICAL  PROTOCOLS  (CARE  PATHS)    One  of  the  most  significant  changes  with  the  enactment  of  AICRA  is  the  established  by  DOBI  of  MEDICAL  PROTOCOLS  (CARE  PATHS)  for  the  treatment  of  identified  injuries,  including  the  utilization  of  diagnostic  tests.    Specifically,  the  treatment  of  accidental  injury  to  the  spine  and  neck  and  set  forth  in  N.J.A.C.  11:3-­‐4.6.    In  the  aforementioned  regulation,  there  were  SIX  CARE  PATHS  

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promulgated.  Specifically:  

CARE  PATH  ONE  (CERVICAL  SPINE:  SOFT  TISSUE  INJURY);  

CARE  PATH  TWO  (CERVICAL  SPINE:  HERNIATED  DISC/RADICULOPATHY);  

CARE  PATH  THREE  (THORACIC  SPINE:  SOFT  TISSUE  INJURY);  

CARE  PATH  FOUR  (THORACIC  SPINE:  HERNIATED  DISC/RADICULOPATHY);  

CARE  PATH  FIVE  (LUMBAR-­‐SACRAL  SPINE:  SOFT  TISSUE  INJURY);  and  

CARE  PATH  SIX  (LUMBAR-­‐SACRAL  SPINE:  HERNIATED  DISC/RADIUCULOPATHY).    As  can  be  easily  seen  by  the  above  list,  the  CARE  PATHS  addressed  three  anatomical  areas  of  the  spine.    Specially,  the  CERVICAL  SPINE,  the  THORACIC  SPINE  and  the  LUMBAR-­‐SACRAL  SPINE.    Thereafter,  each  of  the  aforementioned  three  anatomical  areas  was  subdivided  depending  upon  the  injuries  present.    Specifically,  SOFT  TISSUE  INJURY  and  HERNIATED  DISC/RADICULOPATHY.    Each  of  the  CARE  PATHS  is  attached  hereto  and  a  brief  perusal  of  these  documents  show  the  attempt  by  DOBI  to  make  the  treatment  of  accidental  injury  to  the  spine  and  back,  including  diagnostic  testing,  into  a  flow  chart.    Furthermore,  where  the  CARE  PATH  indicates  a  DECISION  POINT  either  by  a  HEXAGON  or  by  reference  in  the  text  to  a  second  opinion,  referral  for  a  second  independent  consultative  medical  opinion,  development  of  a  treatment  plan  or  mandatory  CASE  MANAGEMENT,  a  DECISION  POINT  REVIEW  is  required.    (N.J.A.C.  11:3-­‐4.6(b)).    The  aforementioned  is  further  described  later  in  this  overview.    In  addition,  it  must  be  noted  that  each  CARE  PATH  specifically  notes  the  following:  

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 "NOTE:  These  CARE  PATHS  identify  typical  courses  of  intervention.    There  may  be  patients  who  require  more  or  less  treatment.    However,  cases  that  deviate  from  the  CARE  PATHS  may  be  subject  to  more  careful  scrutiny  and  may  require  documentation  of  the  special  circumstances.    Treatments  must  be  based  on  patient  need  and  professional  judgment.    Deviations  may  be  justified  by  individual  circumstances,  such  as  pre-­‐existing  conditions  and/or  other  co  morbidities…"    The  aforementioned  NOTE  is  extremely  important  to  the  medical  provider  and  the  supporting  office  staff  since  treatments  that  vary  from  the  CARE  PATHS  shall  be  reimbursable  ONLY  when  warranted  by  reason  of  MEDICAL  NECESSITY.  (N.J.A.C.  11:3-­‐4.6(c)).    Furthermore,  N.J.A.C.  11:3-­‐4.2  defines  MEDICAL  NECESSITY  as:    "The  medical  treatment  or  diagnostic  test  is  consistent  with  the  clinically  supported  symptoms,  diagnosis  or  indications  of  the  injured  person,  and:    

The  treatment  is  the  most  appropriate  level  of  service  that  is  in  accordance  with  the  standards  of  good  practice  and  standard  professional  treatment  protocols  including  the  CARE  PATHS…  The  treatment  of  the  injury  is  not  primarily  for  the  convenience  of  the  injured  person  or  provider;  and  Does  not  include  unnecessary  testing  or  treatment."    Given  the  above,  it  is  imperative  that  the  medical  provider  and  the  supporting  office  staff  carefully  and  meticulously  document  the  symptoms  present  during  each  visit  and  the  treatment  that  was  rendered.    In  addition,  the  aforementioned  documentation  MUST  be  clearly  legible  and  clearly  understandable  to  non-­‐medical  personnel.    The  practical  reason  for  the  aforementioned  assertion  is  that  any  dispute  over  compensation  of  the  medical  services  rendered  will  not  be  finally  adjudicated  by  medical  personnel  but  by  a  DISPUTE  RESOLUTION  PROFESSIONAL  or  a  JUDGE,  either  of  whom  is  generally  NOT  a  trained  medical  person.    The  procedure  for  final  adjudication  will  be  further  discussed  later  in  this  overview.    

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In  addition,  each  CARE  PATH  specifies  the  applicable  ICD-­‐9-­‐CM  codes.      

DIAGNOSTIC  TESTING  DETERMINED  TO  YIELD  NO  DATA  OF  ANY  SIGNIFICANT  VALUE  IN  THE  DEVELOPMENT,  EVALUATION  AND  IMPLEMENTATION  OF  AN  APPROPRIATE  PLAN  OF  TREATMENT  FOR  INJURIES  SUSTAINED  IN  MOTOR  VEHICLE  ACCIDENTS    Pursuant  to  N.J.A.C.  11:3-­‐4.5  (a),  and  another  of  the  major  changes  ushered  in  with  AICRA,  was  that  the  following  diagnostic  tests  shall  not  be  compensated  for  by  PIP  medical  benefits  since  they  have  been  determined  to  yield  no  data  of  any  significant  value  in  the  development,  evaluation  and  implementation  of  an  appropriate  plan  of  treatment  for  injuries  sustained  in  motor  vehicle  accidents:    

1. (RESERVED);  2. SPINAL  DIAGNOSTIC  ULTRASOUND;  3. IRIDOLOGY;  4. REFLEXOLOGY;  5. SURROGATE  ARM  MENTORING;  6. SURFACE  ELECTROMYOGRAPHY  (SURFACE  EMG);  7. (RESERVED);  and  8. MANDIBULAR  TRACKING  AND  STIMULATION.  

In  addition  to  the  above,  and  pursuant  to  N.J.A.C.  11:3-­‐4.5(f),  the  following  diagnostic  tests  shall  not  be  compensated  for  by  PIP  medical  benefits  since  they  have  been  identified  by  the  NEW  JERSEY  STATE  BOARD  OF  DENTISTRY  as  failing  to  yield  data  of  sufficient  volume  to  alter  or  influence  the  diagnosis  or  treatment  plan  employed  to  treat  TMJ/D:  

1. MANDIBULAR  TRACKING;  2. SURFACE  EMG;  3. SONOGRAPHY;  4. DOPPLER  ULTRASOUND;  5. NEEDLE  EMG;  6. ELECTROENCEPHALOGRAM  (EEG);  7. THERMOGRAMS/THERMOGRAPHS;  8. VIDEO  FLUOROSCOPY;  and  9. REFLEXOLOGY.  

DIAGNOSTIC  TESTING  DETERMINED  TO  HAVE  VALUE  IN  THE  

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EVALUATION  OF  INJURIES,  THE  DIAGNOSIS  AND  DEVELOPMENT  OF  A  TREATMENT  PLAN  FOR  PERSONS  INJURED  IN  MOTOR  VEHICLE  ACCIDENTS    Pursuant  to  N.J.A.C.  11:3-­‐4.5  (b),  and  another  of  the  major  changes  ushered  in  with  AICRA,  was  that  the  following  diagnostic  tests  shall  be  compensated  for  by  PIP  medical  benefits  since  they  have  been  determined  to  have  value  in  the  evaluation  of  injuries,  the  diagnosis  and  development  of  a  treatment  plan  for  persons  injured  in  motor  vehicle  accidents:    

1. NEEDLE  ELECTROMYOGRAPHY  (NEEDLE  EMG)  when  used  in  the  evaluation  and  diagnosis  of  neuropathies  and  radicular  syndrome  where  clinically  supported  findings  reveal  a  loss  of  sensation,  numbness  or  tingling.    A  NEEDLE  EMG  is  not  indicated  in  the  evaluation  of  TMJ/D  and  is  contraindicated  in  the  presence  of  infection  on  the  skin  or  cellulitis.    This  test  should  not  normally  be  performed  within  14  days  of  the  traumatic  event  and  should  not  be  repeated  where  initial  results  are  negative.    Only  one  follow  up  exam  is  appropriate.  

2. SOMA  SENSORY  EVOKED  POTENTIAL  (SSEP),  VISUAL  EVOKED  POTENTIAL  (VEP),  BRAIN  AUDIO  EVOKED  POTENTIAL  (BAEP),  or  BRAIN  EVOKED  POTENTIAL  (BEP),  NERVE  CONDUCTION  VELOCITY  (NCV)  and  H-­‐REFLEX  STUDY  are  reimbursable  when  used  to  evaluate  neuropathies  and/or  signs  of  atrophy,  but  not  within  21  days  following  the  traumatic  injury.  

3. ELECTROENCEPHALOGRAM  (EEG)  when  used  to  evaluate  head  injuries,  where  there  are  clinically  supported  findings  of  an  altered  level  of  sensorium  and/or  a  suspicion  of  seizure  disorder.    This  test,  if  indicated  by  clinically  supported  findings,  can  be  administered  immediately  following  the  insured  event.    When  medically  necessary,  repeat  testing  is  not  normally  conducted  more  than  four  times  per  year.  

4. VIDEO  FLUOROSCOPY  only  when  used  in  the  evaluation  of  hypo  mobility  syndrome  and  wrist/carpal  hypo  mobility,  where  there  are  clinically  supported  findings  of  no  range  or  aberrant  range  of  motion  or  dissymmetry  of  facets  exist.    This  test  should  not  be  performed  within  three  months  following  the  insured  event  and  follow  up  tests  are  not  normally  appropriate.  

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5. MAGNETIC  RESONANCE  IMAGING  (MRI)  when  used  in  accordance  with  the  guidelines  contained  in  the  AMERICAN  COLLEGE  OF  RADIOLOGY,  APPROPRIATENESS  CRITERIA  to  evaluate  injuries  in  numerous  parts  of  the  body,  particularly  the  assessment  of  nerve  root  compression  and/or  motor  loss.    MRI  is  not  normally  performed  within  five  days  of  the  insured  event.    However,  clinically  supported  indication  of  neurological  gross  motor  deficits,  incontinence  or  acute  nerve  root  compression  with  neurological  symptoms  may  justify  MRI  testing  during  the  acute  phase  immediately  post  injury.  .  In  the  case  of  TMJ/D  where  there  are  clinical  signs  of  internal  derangement  such  as  nonself-­‐induced  clicking,  deviation,  limited  opening,  and  pain  with  a  history  of  trauma  to  the  lower  jaw,  an  MRI  is  allowable  to  show  displacement  of  the  condylar  disc,  such  procedure  following  a  pantographic  or  Tran  cranial  x-­‐ray  and  six  or  eight  weeks  of  conservative  treatment.  This  TMJ/D  diagnostic  test  may  be  repeated  post  surgery  and/or  post  appliance  therapy.  

6. COMPUTER  ASSISTED  TOMOGRAPHY  STUDIES    (CT,  CAT  Scan)  when  used  to  evaluate  injuries  in  numerous  aspects  of  the  body.    With  the  exception  of  suspected  brain  injuries,  CAT  SCAN  is  not  normally  administered  immediately  post  injury,  but  may  become  appropriate  within  five  days  of  the  insured  event.  Repeat  CAT  SCANS  should  not  be  undertaken  unless  there  is  clinically  supported  indication  of  an  adverse  change  in  the  patient's  condition.  .  In  the  case  of  TMJ/D  where  there  are  clinical  signs  of  degenerative  joint  disease  as  a  result  of  traumatic  injury  of  the  temporomandibular  joint,  tomograms  may  not  be  performed  sooner  than  12  months  following  traumatic  injury.  

7. DYNATRON/CYBER  STATION/CYBEX  when  used  to  evaluate  muscle  deterioration  or  atrophy.    These  tests  should  not  be  performed  within  21  days  of  the  insured  event  and  should  not  be  repeated  if  results  are  negative.    Repeat  tests  are  not  appropriate  at  less  than  six  months  intervals.  

8. SONOGRAMS/ULTRASOUND  when  used  in  the  acute  phase  to  evaluate  the  abdomen  and  pelvis  for  intra-­‐abdominal  bleeding.    These  tests  are  not  normally  used  to  assess  joints  (knee  and  elbow)  because  other  tests  are  more  appropriate.    Where  MRI  is  performed,  SONOGRAM/ULTRASOUND  are  not  necessary.    However,  echocardiogram  is  appropriate  in  the  

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evaluation  of  possible  cardiac  injuries  when  clinically  supported.  9. THERMOGRAPH/THERMOGRAMS  only  when  used  to  evaluate  pain  associated  with  reflex  sympathetic  dystrophy  ("RSD"),  in  a  controlled  setting  by  a  physician  experienced  in  such  use  and  properly  trained.  

10. BRAIN  MAPPING  when  done  in  conjunction  with  appropriate  neurodiagnostic  testing.  

It  must  be  noted  that  the  terms  "normal,"  "normally,"  "appropriate"  and  "indicated"  as  used  above  are  intended  to  recognize  that  no  single  rule  can  replace  the  good  faith  educated  judgment  of  a  health  care  provider.    In  addition,  the  utilization  of  the  aforementioned  terms  is  intended  to  indicate  some  flexibility  and  avoid  rigidity  in  the  application  of  these  rules  in  the  DECISION  POINT  REVIEW.    This  is  further  described  later  in  this  overview.  

TWENTY  ONE  DAY  NOTIFICATION  UPON  COMMENCEMENT  OF  TREATMENT  

Following  the  commencement  of  treatment,  the  medical  provider  and  the  supporting  staff  MUST  advise  the  responsible  PIP  insurance  carrier  within  twenty  ones  days  of  the  commencement  of  treatment.    (N.J.A.C.  11:3-­‐25.4)).      There  are  certain  exceptions  to  the  aforementioned,  however,  the  exceptions  generally  pertain  to  SECONDARY  MEDICAL  PROVIDERS  as  those  who  only  perform  a  medical  service  or  supply  a  care  or  durable  medical  good  following  receipt  of  a  prescription  from  the  treating  medical  provider.    (N.J.A.C.  11:3-­‐25.5(d)(1))  or  if  the  medical  condition  of  the  injured  person  made  it  impossible  to  comply  with  the  notice  requirement  ((N.J.A.C.  11:3-­‐25.5(d)(3)).  

The  notification  to  the  PIP  insurance  carrier  can  be  done  by  utilization  of  the  NOTIFICATION  OF  COMMENCEMENT  OF  MEDICAL  TREATMENT  FORM  approved  by  DOBI  (N.J.A.C.  11:3-­‐25.4(a)(1))  or  by  a  bill  from  the  medical  provider  that  includes  the  following  information:  

1. Name,  address  and  telephone  number  of  the  medical  provider;  2. Name  and  address  of  the  patient;  3. Name  and  address  of  the  insured  (if  different  than  the  patient);  4. Name  and  address  of  the  insurance  company;  5. Policy  Number  of  the  insured;  and  

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6. Date  of  first  treatment.  

(N.J.A.C.  11:3-­‐25.4  (a)(2)).  

Furthermore,  the  aforementioned  notification  can  be  done  by  mail,  facsimile  or  e-­‐mail  to  the  PIP  insurance  company.    (N.J.A.C.  11:3-­‐25.4  (c)).    However,  if  mail  is  utilized,  it  MUST  be  done  by  certified  mail,  return  receipt  requested  to  avoid  a  non-­‐receipt  claim.    

NOTE:  The  addresses  and  facsimile  numbers  of  all  PIP  insurance  carriers  can  be  located  on  the  DOBI  website.    

Failure  to  comply  with  the  aforementioned  twenty  one  day  notice  can  result  in  the  following  reductions  pursuant  to  N.J.A.C.  11:3-­‐25.3(b):  

• 10%  reduction  for  submission  22  to  30  days  late;  • 25%  reduction  for  submission  31  to  60  days  late;  • 50%  reduction  for  submission  61  to  120  days  late;  • 75%  reduction  for  submission  121  to  160  days  late;  and  • 100%  reduction  for  submission  over  161  days  late.  

Furthermore,  any  applicable  reduction  can  not  be  retrieved  directly  from  the  patient  (N.J.A.C.  11:3-­‐25.7),  however,  the  PIP  insurance  carrier  MUST  respond  to  the  treating  medical  provider  within  fourteen  days  of  receipt  of  the  notification.    (N.J.A.C.  11:3-­‐25.3(f)).    As  can  be  clearly  observed  from  aforementioned,  it  is  imperative  that  complete  and  accurate  information  regarding  the  insurance  information  of  the  patient  be  obtained  immediately.    As  such,  the  medical  provider  and  the  supporting  office  staff  must  be  fully  familiar  with  the  concepts  of  PIP  medical  coverage  and  the  correct  PIP  insurance  carrier  that  is  responsible  for  same.    DECISION  POINT  REVIEW  PLAN  (PRIOR  NOTICE,  DECISION  POINTS,  ADDITIONAL  CO-­‐PAYMENT  PENALTY,  TEN  DAY  PERIOD)    In  addition  to  the  promulgation  of  the  MEDICAL  PROTOCOLS  (CARE  PATHS),  the  restriction  on  compensation  for  certain  diagnostic  tests  and  the  determination  of  validity  for  certain  diagnostic  tests,  another  of  the  

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major  changes  ushered  in  with  AICRA  was  the  promulgation  of  DECISION  POINT  REVIEW  PLAN  and  PRE-­‐CERTIFICATION  PLAN.    The  later  will  be  discussed  later  in  this  overview.    Pursuant  to  N.J.A.C.  11:3-­‐4.7,  all  insurers  must  have  a  DECISION  POINT  REVIEW  PLAN  that  provides  for  a  timely  review  of  the  IDENTIFIED  INJURIES  (CARE  PATHS)  at  DECISION  POINTS,  (i.e..  the  previously  referenced  “HEXAGONS”  on  the  CARE  PATHS),  and  for  the  approval  of  the  administration  of  the  DIAGNOSTIC  TESTS  determined  to  have  value  in  the  evaluation  of  injuries,  the  diagnosis  and  development  of  a  treatment  plan  for  persons  injured  in  motor  vehicle  accidents  

• NOTE:  The  definition  of  “DECISION  POINT”  is  set  forth  in  N.J.A.C.  11:3-­‐4.2  and  reads  “those  junctures  in  the  treatment  of  IDENTIFIED  INJURIES  where  a  decision  must  be  made  about  the  continuation  or  choice  of  further  treatment.    DECISION  POINT  also  refers  to  a  determination  to  administer  one  of  the  [approved  diagnostic]  tests…”  

Furthermore,  the  regulation  requires  that  each  DECISION  POINT  REVIEW  PLAN  must  have:    

• Procedures  for  the  injured  person  or  his/her  designee  to  provide  PRIOR  NOTICE  to  the  insurer  or  its  designee  together  with  the  appropriate  CLINICALLY  SUPPORTED  findings  that  additional  treatment  or  the  administration  of  an  approved  DIAGNOSTIC  TEST  are  MEDICALLY  NECESSARY.  (N.J.A.C.  11:3-­‐4.7  (b)(1));  

• The  prompt  review  of  the  notice  and  supporting  materials  submitted  by  the  provider  and  authorization  or  denial  of  reimbursement  for  further  treatment  or  tests.  (N.J.A.C.  11:3-­‐4.7(b)(1)(ii));    NOTE:  There  is  no  specific  time  period  to  define  “prompt  review”  by  statute  or  regulation.    However,  DOBI  BULLETIN  99-­‐05  asserts  that  all  DECISION  POINT  REVIEW  PLANS  must  have  the  time  period  that  the  insurance  carrier  must  affirmatively  deny  the  treatment  or  test.    Furthermore,  if  there  is  “a  failure  to  deny  in  accordance  with  [the]  rule,  [then]  the  treatment  or  test  may  proceed  until  such  time  as  a  denial  based  on  the  determination  of  a  physician  is  

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communicated  by  the  insurer.    The  [DECISION  POINT  REVIEW  PLAN]  should  affirmatively  state  that  if  the  insurer  does  not  respond  within  the  stated  time  frame,  the  provider  may  proceed  with  the  treatment  or  test.    In  addition,  the  [DECISION  POINT  REVIEW  PLAN]  should  provide  that  if  a  physical  or  mental  examination  is  required,  treatment  may  proceed  while  the  exam  is  being  scheduled,  and  until  the  results  are  available.”  

• The  scheduling  of  a  physical  examination  of  the  injured  person  where  the  notice  and  the  supporting  materials  and  other  medical  records  are  not  sufficient  to  authorize  or  deny  reimbursement  of  further  treatment  or  tests.  (N.J.A.C.  11:3-­‐4.7(b)(1)(ii));  

• The  denial  of  reimbursement  for  further  treatment  or  diagnostic  test  shall  be  based  upon  the  determination  of  a  physician.  (N.J.A.C.  11:3-­‐4.7(b)(1)(iii)).  

Furthermore,  the  regulation  also  sets  forth  the  requirements  that  the  physical  examination  must  meet.    Specifically:  

• The  insurance  company  must  notify  the  injured  person  or  his/her  designee  that  a  physical  examination  is  required.  (N.J.A.C.  11:3-­‐4.7(b)(2)(I));  

• The  physical  examination  shall  be  scheduled  within  seven  calendar  days  of  the  receipt  of  the  demand  for  further  treatment  or  tests  UNLESS  the  injured  person  agrees  to  extend  the  time  period.  (N.J.A.C.  11:3-­‐4.7(b)(2)(ii));  

• The  physical  examination  shall  be  conducted  by  a  provider  in  the  same  discipline  as  the  treating  provider.  (N.J.A.C.  11:3-­‐4.7(b)(2)(iii));  

• The  physical  examination  shall  be  conducted  at  a  location  reasonably  convenient  to  the  injured  person.  (N.J.A.C.  11:3-­‐4.7(b)(2)(iv));  

• The  insurance  company  shall  notify  the  injured  person  or  his/her  designee  whether  reimbursement  for  further  treatment  or  tests  is  authorized  as  promptly  as  possible  but  in  no  case  later  than  three  days  after  the  examination.    If  the  examining  provider  prepares  a  written  report  concerning  the  examination,  the  injured  person  or  his/her  designee  shall  be  entitled  to  a  copy  upon  request.  (N.J.A.C.  11:3-­‐4.7  (b)(2)(vi)).  

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Furthermore,  the  regulation  also  sets  forth  that  an  ADDITIONAL  CO-­‐PAYMENT  PENALTY,  not  to  exceed  fifty  percent  (50%)  of  the  eligible  charge  for  medically  necessary  treatment,  diagnostic  tests,  surgery,  durable  medical  goods  and  non-­‐medical  expenses  that  are  incurred  after  notification  to  the  insurer  was  required  but  before  authorization  for  continued  treatment  or  diagnostic  test  is  made  when  the  insurer  is  NOT  notified  as  required  under  the  DECISION  POINT  REVIEW  PLAN  or  if  there  was  a  failure  to  provide  medical  records  and/or  there  was  a  failure  to  attend  the  physical  examination.    However,  the  aforementioned  does  not  apply  if  the  insurer  was  given  PRIOR  NOTICE  and  failed  to  act  in  accordance  with  the  DECISION  POINT  REVIEW  PLAN.    (N.J.A.C.  11:3-­‐4.7(b)(3)).    Furthermore,  all  DECISION  POINT  REVIEW  PLANS,  including  any  PRE-­‐CERTIFICATION  PLANS  (to  be  described  later  in  this  overview),  shall  contain  provisions  for  the  disclosure  of  the  procedures  and  descriptions  of:  

• The  financial  responsibility  of  the  injured  person,  including  co-­‐payments  and  deductibles.  (N.J.A.C.  11:3-­‐4.7(d)(1)(I));  

• The  financial  responsibility  of  the  provider  for  providing  treatment  or  administering  diagnostic  tests  without  authorization  from  the  insurer.  (N.J.A.C.  11:3-­‐4.7(d)(1)(ii);  and  

• How  authorization  for  treatment  and  the  administration  of  diagnostic  tests  may  be  obtained.  (N.J.A.C.  11:3-­‐4.7(d)(1)(iii).  

Furthermore,  no  DECISION  POINT  REVIEW  REQUIREMENTS  shall  apply  within  10  days  of  the  insured  event.    (N.J.A.C.  11:3-­‐4.7(e)).      As  can  be  derived  from  the  pertinent  regulations  noted  above,  each  insurance  company  can  file  its  own  DECISION  POINT  REVIEW  PLAN  for  approval  by  DOBI.    As  such,  the  requirements  can  be  different  for  each  insurance  company,  and  as  such,  the  medical  provider  and  the  supporting  office  staff  MUST  have  a  copy  of  the  pertinent  DECISION  POINT  REVIEW  PLAN  in  order  to  fully  comply  with  all  requirements.    Although  the  aforementioned  will  obviously  require  additional  work  to  the  medical  provider  and  the  supporting  office  staff,  the  alternative  is  the  loss  of  income  for  medical  services  rendered  to  the  patient.    

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In  addition  to  the  above,  when  a  denial  is  rendered  by  the  insurance  company  under  the  DECISION  POINT  REVIEW  PLAN,  any  internal  appeal  procedure  must  be  followed.    As  noted  in  N.J.A.C.  11:3-­‐4.7  (b)(1)(iii),  any  denial  of  reimbursement  for  further  treatment  or  tests  shall  be  based  on  the  determination  of  a  physician.    As  such,  it  is  strongly  recommended  that  when  the  provider  discusses  the  denial  with  the  insurance  company  doctor,  the  following  information  is  obtained  from  the  insurance  company  reviewing  doctor:      

• FULL  NAME  AND  DEGREE;  • STATE  OF  LICENSE  AND  LICENSE  NUMBER;  • EXACT  RECORDS  IN  POSSESSION  OF  REVIEWER;  • IF  CURRENT  PRACTICE  OF  REVIEWER  ALSO  CONSISTS  OF  TREATING  PATIENTS;  

• IF  SO,  THE  PERCENTAGE  THAT  THE  CURRENT  PRACTICE  OF  REVIEWER  TREATS  PATIENTS.  

Also,  many  insurance  carriers  are  utilizing  servicing  agents  for  their  DECISION  POINT  REVIEW  PLANS.    As  such,  documentation  may  be  required  to  be  submitted  to  both  the  insurance  company  and  the  servicing  agent  in  order  to  completely  protect  the  interests  of  the  medical  provider.  

In  addition,  it  must  be  understood  by  the  medical  provider  and  the  supporting  office  staff  that  DECISION  POINT  REVIEW  and  PRE-­‐CERTIFICATION  are  two  completely  separate  topics.    Furthermore,  DECISION  POINT  REVIEW  does  not  mean  that  prior  approval  must  be  obtained  for  future  treatment  under  the  CARE  PATHS  or  for  the  administration  of  the  DIAGNOSTIC  TESTS  listed  as  having  value  in  the  evaluation  of  injuries,  the  diagnosis  and  development  of  a  treatment  plan  for  persons  injured  in  motor  vehicle  accidents.    Instead,  there  will  certainly  be  many  situations  where  the  insurer  denies  authorization  for  the  future  treatment  and/or  diagnostic  testing.    As  long  full  compliance  is  made  under  the  DECISION  POINT  REVIEW  PLAN  and  the  medical  provider  can  document  the  medical  necessity  of  the  treatment  and/or  diagnostic  testing,  compensation  can  be  obtained  for  the  services  rendered  in  the  PIP  DISPUTE  RESOLUTION  process  as  described  later  in  this  overview.  

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PRE-­‐CERTIFICATION  PLANS    Pursuant  to  N.J.A.C.  11:3-­‐4.8,  insurers  may  file  for  approval  with  DOBI  for  a  PRE-­‐CERTIFICATION  PLAN  that  provides  for  pre-­‐certification  of  certain  medical  procedures,  diagnostic  tests,  or  other  services,  non-­‐medical  expenses  and  durable  medical  equipment  that  are  not  subject  to  decision  point  review  and  that  may  be  subject  to  over  utilization.    (N.J.A.C.  11:3-­‐4.8(a))    However,  any  PRE-­‐CERTIFICATION  PLAN  does  not  replace,  or  negate,  the  requirement  to  have  a  DECISION  POINT  REVIEW  PLAN  as  described  previously.      In  addition,  a  PRE-­‐CERTIFICATION  PLAN  can  not  be  utilized  for  treatment  under  the  CARE  PATHS  or  for  utilization  of  the  DIAGNOSTIC  TESTS  determined  to  have  value  in  the  evaluation  of  injuries,  the  diagnosis  and  development  of  a  treatment  plan  for  persons  injured  in  motor  vehicle  accidents.    Furthermore,  the  regulation  required  that  any  PRE-­‐CERTIFICATION  PLAN  must  have:  

• No  restrictions  for  medical  services  rendered  within  ten  days  of  the  insured  event.  (N.J.A.C.  11:3-­‐4.8(c));  

• A  licensed  medical  director  must  be  designated  by  the  insurer  and  the  licensed  medical  director  must  ensure  that:  

• Any  utilization  decision  to  deny  reimbursement  for  further  treatment  or  testing  must  be  made  by  a  physician.    In  the  case  of  treatment  provided  or  prescribed  by  a  dentist,  the  decision  shall  be  by  a  dentist.  (N.J.A.C.  11:3-­‐4.8  (e)(1));  

• A  utilization  management  decision  shall  not  retrospectively  deny  payment  for  treatment  provided  when  prior  approval  has  been  obtained,  unless  the  approval  was  based  upon  fraudulent  information  submitted  by  the  person  receiving  treatment  or  the  provider.  (N.J.A.C.  11:3-­‐4.8  (e)(2));  

• The  utilization  management  program  shall  be  available,  at  a  minimum,  during  normal  working  hours  to  respond  to  authorization  requests.  (N.J.A.C.  11:  3-­‐4.8(e)(3)).    

In  addition,  PRE-­‐CERTIFICATION  PLANS  may  include  provisions  regarding  COMPENSATION  FOR  DURABLE  MEDICAL  GOODS  and  other  services.    Specifically:  

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• The  PRE-­‐CERTIFICATION  PLAN  may  include  a  provision  that  would  require  the  injured  person  to  obtain  the  durable  medical  good  directly  from  the  insurer  or  its  designee.  (N.J.A.C.  11:3-­‐4.8(g));  and  

• The  PRE-­‐CERTIFICATION  PLAN  may  include  an  additional  co-­‐payment,  not  to  exceed  fifty  percent  (50%)  for  medically  necessary  diagnostic  tests,  treatments,  surgery,  durable  medical  equipment  and  non-­‐medical  expenses  that  are  incurred  without  first  complying  with  the  PRE-­‐CERTIFICATION  PLAN.  (N.J.A.C.  11:3-­‐4.8(h)).  

   As  with  the  DECISION  POINT  REVIEW  PLAN,  the  requirements  for  each  insurance  company  can  be  different.    As  such,  the  medical  provider  and  the  supporting  office  staff  MUST  have  a  copy  of  the  pertinent  PRE-­‐CERTIFICATION  PLAN  in  order  to  fully  comply  with  all  requirements.    Although  the  aforementioned  will  obviously  require  additional  work  to  the  medical  provider  and  the  supporting  office  staff,  the  alternative  is  the  imposition  of  a  possible  50%  co-­‐payment  penalty  for  the  services  rendered  that  can  not  be  recovered  from  the  patient.  

PIP  DISPUTE  RESOLUTION  (FORMERLY  “PIP  ARBITRATION”);  (DISPUTE  RESOLUTION  PROFESSION  (“DRP”  AND  FORMERLY  “ARBITRATOR”);  ASSIGNMENT  OF  BENEFITS;  MEDICAL  REVIEW  ORGANIZATION  (“MRO”)  APPLICATION  FOR  DISMISSAL  AND  EMERGENT/EXPEDITED  FILING    Another  major  change  ushered  in  with  AICRA  was  the  overhaul  of  the  former  PIP  ARBITRATION  process.    The  aforementioned  process  was  previously  an  extremely  effective  tool  to  compel  a  PIP  insurance  carrier  to  pay  for  the  reasonable  and  necessary  medical  expenses  rendered  that  were  causally  related  to  a  motor  vehicle  accident.    Although  the  new  process  appears  that  it  will  also  be  effective,  there  are  major  changes  that  were  enacted  by  statute  and  regulation  that  if  not  complied  with  would  result  in  the  denial  of  payment  for  medical  services  rendered.    This  is  more  fully  described  below.    Prior  to  AICRA,  the  AMERICAN  ARBITRATION  ASSOCIATION  was  designated  as  the  sole  adjudicating  authority  for  disputes  being  arbitrated  over  PIP  medical  benefits.    However,  pursuant  to  N.J.A.C.  11:3-­‐

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5.3  (a),  the  COMMISSIONER  of  DOBI  has  the  sole  authority  to  designate  the  organization  to  administer  the  disputes  over  PIP  medical  benefits.    Although  the  AMERICAN  ARBITRATION  ASSOCIATION  remains  the  sole  adjudicating  authority  for  disputes  being  arbitrated  over  PIP  medical  benefits,  the  organization  can  be  replaced  by  DOBI  once  any  contractual  time  period  currently  in  existence  expires.    In  addition  to  the  above,  there  were  certain  vernacular  and  procedural  changes  made  regarding  the  process.    The  most  important  changes  are  described  below.    In  regard  to  the  most  important  vernacular  changes,  the  process  is  no  longer  called  a  PIP  ARBITRATION.    Instead,  the  new  process  is  called  a  PIP  DISPUTE  RESOLUTION.    In  addition,  the  adjudicator  is  no  longer  called  an  ARBITRATOR.    Instead,  the  adjudicator  is  now  called  a  DISPUTE  RESOLUTION  PROFESSIONAL  (DRP).      In  addition  to  the  name  change  to  a  DRP,  there  were  certain  qualifications  imposed  upon  an  individual  to  become  a  DRP  pursuant  to  N.J.A.C.  11:3-­‐5.5(a).    Specifically,  a  DRP  must  be:  

• An  attorney  licensed  to  practice  in  NEW  JERSEY  with  at  least  ten  years  experience  in  cases  involving  personal  injury  or  workers  compensation  (N.J.A.C.  11:3-­‐5.5(a)(1));                -­‐OR-­‐  

• A  former  judge  of  the  SUPERIOR  COURT  or  the  WORKERS  COMPENSATION  COURT,  or  a  former  ADMINISTRATIVE  LAW  JUDGE  (N.J.A.C.  11:3-­‐5.5(a)(2));              -­‐OR-­‐  

• Any  other  person,  qualified  by  education  and  at  least  ten  years  experience,  with  sufficient  understanding  of  automobile  insurance  claims  and  practices,  contract  law,  and  judicial  or  alternative  dispute  resolution  practices  and  procedures  (N.J.A.C.  11:3-­‐5.5(a)(3)).  

The  aforementioned  requirements  have  changed  the  prior  system  of  the  AMERICAN  ARBITRATION  ASSOCIATION  having  a  roster  of  approximately  480  part  time  ARBITRATORS  to  a  current  system  of  the  AMERICAN  ARBITRATION  ASSOCIATION  having  a  roster  of  approximately  25  full  time  DRPs.    The  result  should  create  a  system  of  having  a  staff  of  adjudicators  that  are  fully  familiar  with  the  applicable  

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laws  of  PIP  and  create  a  system  of  uniformity  in  decision  making  that  was  not  always  present  in  the  prior  system.  

In  addition  to  the  aforementioned  vernacular  changes,  there  have  also  been  major  procedural  changes.    However,  instead  of  describing  only  the  changes,  a  full  description  of  the  current  process  is  below.    (NOTE:  All  references  hereafter  to  a  RULE  refer  to  the  RULES  OF  THE  AMERICAN  ARBITRATION  ASSOCIATION.)  

Pursuant  to  RULE  3  (INITIATION  OF  ARBITRATION),  the  initiation  of  a  PIP  DISPUTE  RESOLUTION  commences  with  the  filing  of  a  DEMAND  FOR  ARBITRATION  with  the  AMERICAN  ARBITRATION  ASSOCIATION.    The  filing  must  be  made  with  the  following  documents:  

• DEMAND  FOR  ARBITRATION  FORM;  • FILING  FEE;  • ANY  APPLICABLE  ASSIGNMENT  OF  BENEFITS  FORM;  and  • ITEMIZED  STATEMENT  OF  BILLS  IN  DISPUTE.  

The  entity  filing  the  PIP  DISPUTE  RESOLUTION  is  known  as  the  CLAIMANT  and  the  insurance  carrier  defending  same  is  known  as  the  RESPONDENT.    However,  it  must  be  noted  that  the  entity  filing  the  PIP  DISPUTE  RESOLUTION  does  not  have  to  be  the  injured  person.    Instead,  a  medical  provider  may  file  the  PIP  DISPUTE  RESOLUTION  if  a  proper  ASSIGNMENT  OF  BENEFITS  FORM  has  been  executed  to  the  medical  provider.    This  is  more  fully  described  below.  

Pursuant  to  N.J.A.C.  11:3-­‐4.9,  an  insurance  carrier  may  file  for  approval  with  DOBI  for  “reasonable  procedures  for,  or  restrictions  on,  the  assignment  of  personal  injury  benefits,  consistent  with  the  efficient  administration  of  the  coverage.”    As  such,  it  is  imperative  for  a  medical  provider  to  obtain  any  required  ASSIGNMENT  OF  BENEFITS  FORM  to  be  executed  by  the  patient  from  the  responsible  insurance  carrier.    Of  course  this  is  in  addition  to  the  medical  provider  complying  with  all  requirements  of  the  TWENTY  ONE  DAY  NOTIFICATION,  DECISION  POINT  REVIEW  PLAN  and  PRE  CERTIFICATION  PLAN.  

   If  the  aforementioned  is  complied  with,  then  the  medical  provider  can  become  the  direct  CLAIMANT  against  the  responsible  insurance  carrier.    This  is  not  only  a  preferable  position  for  the  medical  provider  but  

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a  practical  position  since  any  dispute  over  PIP  medical  benefits  will  be  directly  between  the  true  financial  parties  in  a  dispute  over  PIP  medical  benefits,  namely,  the  medical  provider  and  the  insurance  carrier.  

The  forum  for  adjudication  of  a  PIP  DISPUTE  RESOLUTION  can  be  by  WRITTEN  DOCUMENT  SUBMISSION  or  by  ORAL  HEARING  pursuant  to  RULE  4  (CHOOSING  ORAL  HEARINGS  OR  DISPUTE  RESOLUTION  PROFESSIONAL  REVIEW  OF  DOCUMENTS).    However,  if  the  CLAIMANT  elects  a  WRITTEN  DOCUMENT  SUBMISSION  forum,  the  RESPONDENT  has  the  right  to  demand  an  ORAL  HEARING  instead  if  the  demand  to  change  the  forum  of  adjudication  is  done  within  thirty  days  of  the  filing  for  the  PIP  DISPUTE  RESOLUTION.  

Once  the  filing  has  occurred,  the  AMERICAN  ARBITRATION  ASSOCIATION  will  appoint  a  DRP  to  adjudicate  the  PIP  DISPUTE  RESOLUTION  pursuant  to  RULE  8  (APPOINTMENT  OF  DISPUTE  RESOLUTION  PROFESSIONAL).    However,  a  three  DRP  panel  can  also  adjudicate  the  PIP  DISPUTE  RESOLUTION  if:  

• Both  parties  agree  to  the  three  DRP  panel;            -­‐OR-­‐  • The  amount  claimed  exceeds  $50,000.00  AND  the  request  is  made  within  thirty  days  of  the  filing  for  the  PIP  DISPUTE  RESOLUTION.  

Notwithstanding  the  aforementioned,  there  are  practical  reasons  against  the  selection  of  a  three  DRP  panel.    Most  importantly,  the  monetary  cost  of  the  filing  fee.  

As  noted  earlier,  the  initiation  of  the  PIP  DISPUTE  RESOLUTION  must  also  include  the  filing  fee.    The  filing  fee  cost  for  a  WRITTEN  DOCUMENT  SUBMISSION  is  $275.00  while  the  filing  fee  cost  for  an  ORAL  HEARING  is  $325.00.    However,  if  a  three  DRP  panel  is  requested,  there  is  an  additional  $800.00  filing  fee  cost  added  on  to  the  aforementioned  figures.  

Once  the  DRP  is  appointed,  either  party  may  challenge  the  appointment  within  twenty  days  of  the  appointment  for  “reasonable  cause”  pursuant  to  RULE  8  (APPOINTMENT  OF  DISPUTE  RESOLUTION  PROFESSIONAL).    Furthermore,  RULE  8  (APPOINTMENT  OF  DISPUTE  RESOLUTION  PROFESSIONAL)  provides  that  “reasonable  cause”  may  include  application  of  the  principles  outlined  in  the  CODE  OF  JUDICIAL  CONDUCT.    However,  and  as  a  practical  matter,  it  is  extremely  difficult  to  

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remove  a  DRP  unless  an  ACTUAL  financial  or  personal  interest  can  be  shown.  

Once  the  time  period  to  challenge  the  appointment  of  a  DRP  has  expired,  a  discovery  period  occurs  where  the  exchange  of  information  between  the  parties  occurs.    However,  since  the  PIP  DISPUTE  RESOLUTION  is  not  a  court  proceeding,  the  COURT  RULES  pertaining  to  discovery  do  not  specifically  apply.    In  addition,  and  pursuant  to  RULE  21  (EVIDENCE),  the  “DRP  shall  be  the  judge  of  the  relevancy  and  materiality  of  the  evidence  offered,  and  conformity  to  legal  rules  of  evidence  shall  not  be  necessary.”    Furthermore,  and  pursuant  to  RULE  22  (EVIDENCE  BY  AFFIDAVIT  OR  DOCUMENT),  the  “DRP  may  receive  and  consider  the  evidence  of  witnesses  by  affidavit  or  other  document,  but  shall  give  it  only  such  weight  as  the  DRP  deems  it  entitled  to  after  consideration  of  any  objection  made  to  its  admission.”  

Pursuant  to  RULE  17  (EXCHANGE  OF  INFORMATION),  “the  DRP  may  establish  the  extent  of  and  schedule  for  any  such  exchange  pertaining  to  the  subject  matter  of  the  arbitration,  including,  but  not  limited  to  the  [discovery]  outlined  in  N.J.S.  39:6A-­‐13  or  provided  by  the  applicable  policy  of  insurance.”      The  aforementioned  discovery  includes:  

• PRODUCTION  OF  WRITTEN  REPORT  OF  PATIENT  HISTORY,  CONDITION,  TREATMENT,  DATES  AND  COSTS  OF  TREATMENT  BY  MEDICAL  PROVIDER    (N.J.S.  39:6A-­‐13(b));  

• SUBMISSION  TO  MENTAL  AND/OR  PHYSICAL  EXAMINATION  BY  PATIENT    (N.J.S.  39:6A-­‐13(d));    NOTE:  If  a  MENTAL  and/or  PHYSICAL  EXAMINATION  is  demanded  by  the  insurance  carrier,  the  aforementioned  statute  also  requires  that  the  “examination  shall  be  conducted  within  the  municipality  of  residence  of  the  injured  person…if  there  is  no  qualified  health  care  provider  to  conduct  the  examination  within  the  municipality  of  residence  of  the  injured  person,  then  such  examination  shall  be  conducted  in  an  area  of  the  closest  proximity  to  the  injured  person’s  residence.”)  

• PRODUCTION  OF  EXAMINATION  REPORT  TO  PATIENT    (N.J.S.  39:6A-­‐13(e));  

• SUBMISSION  TO  STATEMENT  UNDER  OATH/EXAMINATION  

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UNDER  OATH  BY  PATIENT  (POLICY  OF  INSURANCE).  

Besides  the  above  mentioned  discovery  tools,  SUBPOENAS  may  be  issued  by  the  DRP,  or  an  attorney  representing  a  party,  for  evidence  that  is  relevant  and  material  to  the  dispute  pursuant  to  RULE  21  (EVIDENCE).    However,  the  production  of  additional  evidence  by  a  party  is  subject  to  what  “the  DRP  may  deem  necessary  to  an  understanding  and  determination  of  the  dispute  in  order  to  make  a  decision”  pursuant  to  the  aforementioned  RULE.    As  such,  an  overbroad  SUBPOENA  can  be  squashed  following  an  application  for  same  with  the  DRP.  

   In  addition  to  the  above,  and  ushered  in  with  AICRA,  is  the  review  by  a  MEDICAL  REVIEW  ORGANIZATION  ("MRO")  pursuant  to  RULE  21A  (ACCESS  TO  MEDICAL  EXPERTISE).    The  parameters  of  a  review  by  an  MRO  are:  

• Whether  the  medical  treatment  or  diagnostic  test  is  medically  necessary    (N.J.A.C.  11:3-­‐5.8(a)(1));  

• Whether  the  treatment  is  in  accordance  with  medically  necessary  recognized  standard  protocols  including  those  protocols  approved  by  DOBI    (N.J.A.C.  11:3-­‐5.8(a)(2));  

• Whether  the  treatment  is  consistent  with  symptoms  or  diagnosis  of  the  injury    (N.J.A.C.  11:3-­‐5.8(a)(3));  

• Whether  the  injury  is  causally  related  to  the  accident    (N.J.A.C.  11:3-­‐5.8(a)(4));  

• Whether  the  treatment  is  of  a  palliative  rather  than  a  restorative  nature    (N.J.A.C.  11:3-­‐5.8(a)(5));  

• Whether  medical  procedures  and  tests  that  have  been  repeated  are  medically  necessary    (N.J.A.C.  11:3-­‐5.8(a)(6)).  

The  findings  of  an  MRO  shall  be  presumed  to  be  correct,  but  may  be  rebutted  by  a  preponderance  of  the  evidence  submitted  to  the  DRP.    (N.J.A.C.  11:3-­‐5.8(b)).  

 As  previously  mentioned,  the  time  period  for  the  aforementioned  discovery  period  is  set  by  the  DRP  pursuant  to  RULE  17  (EXCHANGE  OF  INFORMATION)  except  if  the  parties  mutually  agree  to  a  modification  of  a  time  period  pursuant  to  RULE  26  (EXTENSION  OF  TIME).    Furthermore,  separate  rules  pertain  if  the  forum  for  adjudication  is  a  WRITTEN  DOCUMENT  SUBMISSION  or  an  ORAL  HEARING  and  each  will  be  

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discussed  separately  below.  

If  the  forum  for  adjudication  is  a  WRITTEN  DOCUMENT  SUBMISSION,  then  the  deadline  for  submission  of  proofs  is  set  by  the  DRP  pursuant  to  RULE  21  (EVIDENCE).    Thereafter,  the  other  party  shall  have  ten  days  from  receipt  to  respond  to  same.  

However,  if  the  forum  for  adjudication  is  an  ORAL  HEARING,  then  a  copy  of  any  document  that  a  party  intends  to  rely  upon  must  be  provided  to  the  other  party  at  least  twenty  days  before  the  date  of  the  ORAL  HEARING  set  by  the  DRP  pursuant  to  RULE  17  (EXCHANGE  OF  INFORMATION).    Failure  to  do  so  may  result  in  the  barring  of  such  evidence  at  the  discretion  of  the  DRP.    

In  addition  to  the  above,  if  one  or  more  parties  do  not  appear  at  the  ORAL  HEARING,  the  DRP  must,  “in  the  presence  of  all  other  parties,  place  a  call  to  the  party…not  appearing”  pursuant  to  RULE  20  (ARBITRATION  IN  THE  ABSENCE  OF  A  PARTY).    Thereafter,  the  DRP  can  determine  to  proceed  or  adjourn  the  ORAL  HEARING,  allow  telephonic  participation  and  supplemental  written  submissions.  

It  must  be  noted  that  pursuant  to  RULE  25  (WAIVER  OF  RULES)  that  any  party  who  proceeds  with  a  PIP  DISPUTE  RESOLUTION  after  knowledge  that  any  provision  or  requirement  of  the  applicable  RULES  has  not  been  complied  with  will  be  deemed  to  have  waived  the  right  to  object  to  said  violation.    To  preserve  the  right  of  objection,  the  aforementioned  RULE  requires  that  the  objection  must  be  stated  in  writing.  

Once  the  PIP  DISPUTE  RESOLUTION  proceedings  are  closed,  a  reopening  is  permitted  pursuant  to  RULE  24  (REOPENING  OF  HEARING)  before  an  AWARD  is  rendered.    The  reopening  may  be  done  at  the  initiative  of  the  DRP  or  upon  request  of  a  party  for  good  cause  shown.    However,  the  aforementioned  RULE  prohibits  the  reopening  of  the  PIP  DISPUTE  RESOLUTION  proceedings  by  the  DRP  for  new  evidence  without  the  consent  of  all  the  parties  involved.  

Within  forty  five  days  from  the  close  of  the  PIP  DISPUTE  RESOLUTION  proceedings,  or  the  reopened  proceedings,  the  DRP  shall  render  an  AWARD  pursuant  to  RULE  28  (TIME  OF  AWARD).    However,  the  aforementioned  time  period  may  be  changed  by  mutual  consent  of  the  

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parties  involved.  

The  form  of  the  AWARD  is  set  forth  in  RULE  29  (FORM  OF  AWARD)  and  N.J.A.C.  11:3-­‐5.6(d).    As  such,  the  AWARD  must  be  in  writing,  signed  by  the  DRP  and  must  state:  

• The  issues  in  dispute;  • The  findings  of  the  DRP;  • The  legal  conclusions  of  the  DRP;  and  • If  the  determination  of  a  MRO  is  overcome  by  a  preponderance  of  the  evidence,  the  reasons  supporting  that  finding.  

   In  addition,  the  AWARD  must  be  made  in  accordance  with  applicable  principles  of  substantive  law,  the  provisions  of  the  applicable  insurance  policy  and  the  regulations  promulgated  by  DOBI.    Furthermore,  the  AWARD  must  set  forth  a  decision  on  all  issues  submitted  by  the  parties  for  resolution.  

It  must  be  noted  that  pursuant  to  N.J.A.C.  11:3-­‐5.6(e),  if  an  AWARD  “requires  payment  by  the  insurer  for  a  treatment  or  test,  payment  shall  be  made,  together  with  any  accrued  interest  pursuant  to  N.J.S.  39:6A-­‐5,  within  20  days  of  receipt  of  a  copy  of  the  determination.”  

Following  receipt  of  the  AWARD,  and  pursuant  to  RULE  35  (MODIFICATION/  CLARIFICATION),  a  party  may  request  that  the  DRP:  

• Clarify  the  AWARD;          -­‐OR-­‐  • Correct  any  clerical,  typographical  or  computational  errors;          -­‐OR-­‐  • Make  an  additional  AWARD  as  to  claims  presented  to  the  DRP  but  omitted  from  the  AWARD.  

However,  the  application  for  the  aforementioned  must  be  made  within  twenty  days  of  the  receipt  of  the  AWARD.    Furthermore,  any  objection  to  the  aforementioned  must  be  made  within  ten  days  after  the  AMERICAN  ARBITRATION  ASSOCIATION  acknowledges  the  receipt  of  the  request  pursuant  to  RULE  35  (MODIFICATION/CLARIFICATION).  

In  addition  to  the  above,  a  party  may  appeal  the  AWARD  pursuant  to  RULE  36  (APPEALS  UNDER  THESE  RULES).    As  with  a  request  made  pursuant  to  RULE  35  (MODIFICATION/CLARIFICATION),  a  party  making  

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an  appeal  must  do  so  within  twenty  days  from  the  date  the  AWARD  was  mailed.    However,  an  appeal  made  under  RULE  36  (APPEALS  UNDER  THESE  RULES)  must  also  include  a  filing  fee  of  $1050.00.  

An  appeal  made  pursuant  to  RULE  36  (APPEALS  UNDER  THESE  RULES)  will  be  decided  by  a  three  DRP  panel,  none  of  whom  being  the  DRP  that  rendered  the  initial  AWARD.    All  decisions  and  rulings  by  a  aforementioned  APPEAL  PANEL  must  be  made  by  majority  and  the  AWARD  being  appealed  may  only  be  vacated  or  modified  if  it  was  incorrect  as  a  matter  of  law.  

As  noted  above,  there  is  a  twenty  day  time  period  following  receipt  of  an  AWARD  for  a  party  to  file  for  a  modification  or  clarification  of  the  AWARD  under  RULE  35  (MODIFICATION/  CLARIFICATION)  or  an  appeal  of  the  AWARD  under  RULE  36  (APPEALS  UNDER  THESE  RULES).    Furthermore,  and  as  also  noted  above,  N.J.A.C.  11:3-­‐5.6(e),  “requires  payment  by  the  insurer  for  a  treatment  or  test,  payment  shall  be  made,  together  with  any  accrued  interest  pursuant  to  N.J.S.  39:6A-­‐5,  within  20  days  of  receipt  of  a  copy  of  the  [AWARD].”  

Given  the  above,  following  the  expiration  of  twenty  days  following  receipt  of  the  AWARD,  all  administrative  remedies  available  under  the  RULES  of  the  AMERICAN  ARBITRATION  ASSOCIATION  have  been  exhausted.    Furthermore,  any  payment  required  by  the  insurance  carrier  is  considered  overdue.    As  such,  the  next  step  would  be  a  filing  of  a  COMPLAINT  in  the  SUPERIOR  COURT  to  either  vacate  the  AWARD,  modify  the  AWARD  or  confirm  the  AWARD  into  a  JUDGMENT.    The  aforementioned  will  be  briefly  described  below.  

The  statutory  authority  for  the  filing  of  a  COMPLAINT  in  the  SUPERIOR  COURT  is  derived  from  N.J.S.  2A:24-­‐8.    However,  and  pursuant  to  the  holding  of  TRETINA  PRINTING,  INC.  v.  FITZPATRICK  &  ASSOCIATES,  INC.,  135  N.J.  349,  358  (1994),  an  AWARD  will  be  overturned  only  on  a  showing  of  fraud  or  corruption  on  the  part  of  the  arbitrator.    As  such,  the  practical  application  of  the  filing  of  a  COMPLAINT  in  the  SUPERIOR  COURT  is  that  the  AWARD  is  binding  upon  the  part