Ask the Legal Expert: Appeal Rejections

Feb 20, 2024 | ANJC News & Updates

By Jeffrey Randolph, Esq., ANJC Legal Counsel

Q: I attempted to appeal through the DOBI Appeal Process a Horizon denial of E&M Services, and it was rejected on the basis that it was a Self-Funded plan. Is this correct?

A: That is correct. If you are dealing with a self-funded plan, this means that Horizon only acts as a plan “administrator” for a self-insured employer and does not pay the actual claims. Self-funded plans are not regulated by the New Jersey Department of Banking and Insurance; rather, they are regulated by the US Department of Labor and the federal ERISA law. Thus, the 2009 DOBI administrative action decision is not officially binding upon self-funded plans.

However, this does not permit Horizon to impose its own reimbursement policy when reimbursing
self-funded plan claims. Horizon should be following the policy language of the self-funded plan, not their own. If the self-funded plan policy language as it relates to chiropractic benefits does not provide for bundling
of E&M into Chiropractic Manipulative reimbursement, then Horizon as plan administrator should not be adding their own reimbursement policy where it does not exist in the self-funded plan language. You should request a copy of the self-funded plan’s summary plan description (“SPD”), which must be provided under
ERISA, to determine what the actual self-funded policy states regarding chiropractic benefits.

Q: I attempted to appeal through the DOBI Appeal Process a Horizon denial of E&M Services, and it was rejected on the basis that it was a State Health Benefits plan covering a State Employee. Is this correct?

A: This is correct. Similar to self-funded plans addressed in the previous question, State Health Benefits Plans such as NJPLUS and NJDIRECT have their own appeal process separate and apart from the DOBI appeal process. In general, you must initiate the first-level appeal within twelve months of a denial by calling the State Health Benefit Plan to receive instructions on how to submit a written appeal. You will be notified of second-level appeal rights if denied at first level.

Q: I received a request from a PIP Insurance Company Asking for Over Thirty Different Types of Information regarding my practice structure, my employees, and my practice finances. Do I have to provide this information?

A: As of this point in time, no, you do not unless you have received a court order, subpoena, or discovery order from an arbitrator in a pending PIP arbitration requiring you to do so. New Jersey No-Fault law only requires disclosure of the following information with regard to your PIP claims: “facts about the injured person’s earnings or about his history, condition, treatment, dates and costs of such treatment…” The New Jersey Appellate Division recently addressed this issue on October 7, 2010, in their decision in Selective Insurance Company v. Hudson East Pain Management, A-0433-09T1 (Approved for Publication). In this case, the Appellate Division held that PIP carriers cannot request disclosure of confidential business information such as corporate charters, partnership agreements, annual reports, shareholder agreements and lease agreements as a condition to the payment of PIP benefits. The Court reasoned that an assignment of benefits from a patient to a health care provider assigns the right to be paid directly and to pursue appeal or arbitration of unpaid claims but does not assign to the provider the duties that the insured has under the PIP policy to cooperate with the insurer’s investigation, such as attending Examinations Under Oath or providing other discovery.

It appears that the vast majority of the information requested from you concerns the information the Appellate Division has held is not discoverable and you would not have to reply. However, there are two caveats. First, the Appellate Division case has been appealed to the Supreme Court which could overturn the decision once it is reviewed. Second, you should always consult with your own attorney when responding to such a request, as there could be unique, fact-specific issues that cannot be addressed in a general response such as this.

Jeff Randolph

The author of Legal Ease/Legal Q&A (Jeffrey Randolph, Esq.) is an independent person of the ANJC, and his views are not authorized, sponsored, or otherwise approved by the A.N.J.C. The information provided is for general guidance on matters of interest only and may not take into account particular facts relevant to your individual situation. The application and impact of laws and health care can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations, there may be omissions or inaccuracies in information contained in these materials.

Accordingly, the information you receive is provided with the understanding that the author and the A.N.J.C. are not herein engaged in rendering legal, accounting, tax, health care or other professional advice and services nor are they providing specific advice with regard to your practice, the treatment of any specific illness, disease, deformity or condition, or any other matter that affects trade, commerce, or legal rights of others. As such, this article should not be used as a substitute for consultation with professional accounting, tax, legal, health care, or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional.