N.J. Admin. Code § 11:3-28.1

Current through Register Vol. 56, No. 12, June 17, 2024

Section 11:3-28.1 - Purpose and scope

(a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimburseable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $ 10,000 or more submitted by licensed providers of health care services or claims of $ 25,000 or more by health care facilities; and requiring prior approval of claims for alterations to vehicles and residences. This subchapter also requires insurers to pursue the proper, alternative sources for reimbursement where such other sources of funds are available.

(b) This subchapter applies to all insurers authorized in this State to write the kinds of insurance specified in paragraphs d and e of 17:17-1. In accordance with 39:6-73.1, reimbursement for medical expense benefits may be sought from the Fund on account of personal injury to any one person in any one accident occurring on or after February 19, 1978.

(c)11:3-28.1 3 establishes standards for insurers to demonstrate diligent pursuit of any potentially responsible tortfeasor for the purpose of recovering PIP medical expense benefits paid on behalf of the injured party by the Fund. Insurers shall obtain reimbursement from the Fund for excess medical expense benefit payments once they comply with the standards established herein. The purpose of these provisions are to contain costs for automobile insurance in this State. Accordingly, consistent with this purpose and 39:6A-9.1, for accidents occurring outside this State, insurers are expected to assert appropriate legal remedies to pursue recovery actions against potentially responsible tortfeasors, consistent with the legal rights and remedies asserted by the injured party.

N.J. Admin. Code § 11:3-28.1

Repeal and New Rule, R.1993 d.583, effective 11/15/1993.
See: 25 New Jersey Register 2636(b), 25 New Jersey Register 5219(a).
Section was "Notification of potential for payment of excess medical expense benefits".
Amended by R.2001 d.151, effective 5/7/2001.
See: 32 New Jersey Register 3714(a), 33 New Jersey Register 1389(a).
In (b), added the second sentence; added (c).