New PIP Uniform Appeal Forms and Process Takes Effect April 17, 2017
On Oct. 17, 2016, the New Jersey Department of Banking and Insurance (DOBI) published in the N.J. Register amendments to the PIP regulations implementing a new, mandatory appeal process for PIP claims to take effect April 17th.
DOBI has published on its website the new Uniform Appeal Forms for Pre-Service and Post-Service appeals. The forms can be downloaded here in both .pdf and fillable Excel versions. There is also a Frequently Asked Questions document available on the website.
You must start using these new forms and procedures for appeals filed on or after April 17, 2017.
A Pre-Service Appeal is essentially a denial or reduction of your precertification request by the carrier. Pre-service appeals have a 30 day deadline to appeal from the denial of precertification and the carrier must issue a determination within 14 days of receipt of the appeal or requested documentation. There is a separate and distinct Pre-Service appeal form so make sure that you submit the correct form.
A Post-Service Appeal is essentially a non-payment or reduction in payment on the Explanation of Benefit form you receive in response to your billing after treating the patient. This may include coding issues, bundling of codes, improper precertification penalties, and other non-medical necessity based denials or reductions. Post-service appeals must be filed at least 45 days before arbitration or Superior Court litigation and the carrier must respond within 30 days of receipt of the appeal or requested documentation. Again, there is a separate and distinct Post-Service appeal form so make sure that you submit the correct form.
The PIP appeal process is defined in detail for each PIP carrier in their Decision Point Review (“DPR”) Plan which is mailed to the provider upon receipt of a notice of commencement of care. Each DPR plan may differ but the regulations do not mandate that carriers have to accept appeals by fax. The PIP regulations provide the option to carriers to accept appeals by electronic means, which includes fax and possibly other electronic submissions in the future, but it does not mandate this. Thus, you must check each carriers DPR plan to see what process is required to properly submit an appeal, which may include snail mail or certified mail and the proper address to submit the appeals to.
More information will be provided by the ANJC in subsequent notices and the ANJC will soon be scheduling a statewide call or webinar to go through the new appeal process in detail so stay tuned.
Jeffrey Randolph, Esq.
ANJC Legal Counsel
The author of this notice 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.