N.J. Admin. Code § 11:3-25.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:3-25.3 - Notification of commencement of treatment

(a) When medical treatment is rendered for which a claim for payment will be made pursuant to the PIP coverage of a private passenger automobile insurance policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of the commencement of such treatment.

(b) In accordance with the PIP information provided by the injured party or the insured, notice shall be sent by the treating health care provider to the insurer at the address established by the insurer for the receipt of such notice.

(c) Insurers shall establish one address where notice must be sent by treating health care providers pursuant to these rules. Insurers shall provide this address, and may provide a facsimile transmission number, and E-mail address if any, on all insurance identification cards issued by the insurer after January 6, 1997.

(d) In accordance with the provisions of 11:3-25.1 0, insurers shall file with the Department the address, and may provide a facsimile transmission number, and E-mail address, if any, where notice of commencement of treatment should be sent. Insurers shall also include the name and telephone number of a contact person at the insurer for this purpose. Such information shall be added to a list of insurer addresses maintained by the Department.

(e) Notice sent to the address printed on a valid insurance identification card or on the Department's current list of addresses shall be presumed to have been sent to the proper address.

(f) Within 14 days after receiving notice of the commencement of treatment, the insurer shall notify the treating health care provider of the coverage status of the person receiving treatment. If the notice from the insurer states that the coverage status of the person receiving treatment is unknown, the insurer shall make a determination of coverage and provide written confirmation to the treating health care provider no later than 60 days from receipt of notice of commencement of treatment. Examples where the coverage status may not be known are when the injured person is not a named insured, principal or occasional operator, or is not otherwise listed as a resident of the insured household on the most recent information provided to the insurer by the named insured.

(g) The notice requirements set forth in (a) through (c) above and the eligible charge reductions contained in 11:3-25.5 shall not apply to secondary medical providers, except as noted in the definition of that term found in 11:3-25.2.

(h) In calculating the time for notice in (a) and (f) above, the day treatment begins or the day the insurer receives notice from the treating health care provider is not to be included. If the last day for providing notice falls on a Saturday, Sunday or legal holiday, the time runs to the next business day.

N.J. Admin. Code § 11:3-25.3

Amended by R.1998 d.591, effective 12/21/1998 (operative March 22, 1999).
See: 30 New Jersey Register 3202(a), 30 New Jersey Register 4390(b).
Substituted references to health care providers for references to medical providers throughout.