On November 2, 2015, the New Jersey Department of Banking and Insurance (NJDOBI) published the long-awaited repeal and proposed replacement of N.J.A.C. 11:3-4.7B, which had established standards for a uniform internal appeal process for disputes by providers assigned benefits by an insured under the personal injury protection (PIP) coverage of New Jersey automobile insurance policies. Insurers have been required to have in place internal appeal processes as part of their decision point review plans for some time. However, because of a lack of uniformity among insurers, provider appeals have been confusing and cumbersome. The NJDOBI has determined to repeal and replace the process in its entirety, in order to simplify the requirements for internal appeals to promote the cost efficient provision of medical care to persons injured in automobile accidents.

Similar to the existing procedure adopted effective November 12, 2012, the proposal requires insurers to establish a one-level appeal system. The proposal divides appeals into pre-service (appeals of decision point review and/or precertification or modifications prior to service) and post-service (appeals filed after the performance of service), on a uniform form established by the NJDOBI. The procedure shall be one level for each issue appealed, so that medical necessity and reimbursement are each treated as separate appeals. The proposal also sets in place uniform time limitations for such filings and requires insurers to establish an internal appeal procedure in its decision point review plan meeting the requirements of the rule. By eliminating the differences in practices and establishing a uniform process, the NJDOBI seeks to make it easier and more efficient for providers to file such appeals.

A copy of the NJDOBI’s proposal may be accessed here. Comments to the proposal may be submitted to the NJDOBI by January 1, 2016.



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