N.J. Admin. Code § 11:3-25.5

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

Section 11:3-25.5 - Late notification

(a) In the event notice of commencement of medical treatment is made after 21 days, the insurer shall advise the treating health care provider in writing of the late notification and may reserve the right to reduce payment in accordance with (b) below.

(b) Where notice of the commencement of medical treatment is not timely provided in accordance with this subchapter, an insurer may apply the following reductions to the eligible charges:

1. 22 to 30 days after the commencement of treatment: 10 percent reduction.

2. 31 to 60 days after the commencement of treatment: 25 percent reduction.

3. 61 to 120 days after the commencement of treatment: 50 percent reduction.

4. 121 to 160 days after the commencement of treatment: 75 percent reduction.

5. 161 or more days from the commencement of treatment: 100 percent reduction.

(c) If notice is not provided as required by this subchapter, the reduction formula set forth in (b) above shall apply to all eligible charges for which the treating health care provider seeks payment through such late notice.

(d) Insurers shall not reduce an eligible charge under the following circumstances:

1. When the provider is a member of the group of multiple treating health care providers giving emergency care during the initial hospitalization as defined in 11:3-25.2;

2. When the provider is a secondary medical provider as defined in 11:3-25.2;

3. When the medical condition of the injured party made it impossible to comply with the notice requirement; or

4. When the provider has submitted a request for decision point review or precertification of treatment, diagnostic testing or durable medical equipment in accordance with an insurer's decision point review plan approved in accordance with 11:3-4.7.

N.J. Admin. Code § 11:3-25.5

New Rule, R.1997 d.14, effective 1/6/1997 (operative March 7, 1997).
See: 28 New Jersey Register 3876(a), 29 New Jersey Register 132(a).
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.
Amended by R.2004 d.218, effective 6/7/2004.
See: 35 New Jersey Register 3072(a), 36 New Jersey Register 2890(a).
In (d), added 4.