N.J. Admin. Code § 11:3-4.7

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

Section 11:3-4.7 - Decision point review plans

(a) No insurer shall impose the co-payments permitted in 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan.

1. Initial decision point review plan filings and amendments to approved plans shall be submitted to the Department through the use of the NAIC electronic filing system SERFF (System for Electronic Rate and Form Filing).

(b) No decision point or precertification requirements shall apply within 10 days of the insured event or to emergency care. This provision should not be construed so as to require reimbursement of tests and treatment that are not medically necessary.

(c) A decision point review plan filing shall include the following information:

1. Identification of any PIP vendor with which the insurer has contracted and a copy of the contract between the insurer and the PIP vendor. No insurer shall contract with a PIP vendor unless the vendor is registered with the Department pursuant to 11:3-4.7A;

2. Identification of any specific medical procedures, treatments, diagnoses, diagnostic tests, other services or durable medical equipment that are subject to precertification. The inclusion of precertification requirements in a decision point review plan is optional. The medical procedures, treatments, diagnoses, diagnostic tests or durable medical equipment required to be precertified shall be those that the insurer has determined may be subject to overutilization and that are not already subject to decision point review. The insurer shall not require the precertification of a new-patient evaluation and management visit that is necessary for the provider to develop the plan of care that is incorporated into a precertification request for treatment or diagnostic testing;

3. Copies of the informational materials described in (d) below and an explanation of how the insurer will distribute information to policyholders, injured persons and providers at policy issuance, renewal and upon notification of claim.

4. Procedures for the prompt review, not to exceed three business days, of decision point review and precertification requests by insureds or providers. All determinations on treatments or tests shall be based on medical necessity and shall not encourage over or underutilization of benefits. Denials of decision point review and precertification requests on the basis of medical necessity shall be the determination of a physician. In the case of treatment prescribed by a dentist, the denial shall be by a dentist;

5. Procedures for the scheduling of physical examinations pursuant to (e) below;

6. An internal appeals procedure that permits the provider to provide additional information and have a rapid review of a decision to modify or deny reimbursement for a treatment or the administration of a test;

7. Reasonable restrictions on the assignment of benefits pursuant to 11:3-4.9(a);

8. Reasonable restrictions on what types of providers may submit decision point review requests; and

9. The information required in order to use a network pursuant to 11:3-4.8(d), if applicable.

(d) The informational materials for policyholders, injured persons and providers shall be on forms approved by the Commissioner and shall include at a minimum the information in (d)1 through 9 below. In order to make the requirements of this subchapter easier for insureds and providers to use, the Commissioner may by Order require the use of uniform forms, layouts and language of information materials.

1. How to contact the insurer or vendor to submit decision point review/precertification requests including the telephone, facsimile numbers, e-mail addresses or through a website. The insurer or its vendor shall be available, at a minimum, during normal working hours to respond to decision point review/precertification requests;

2. An explanation of the decision point review process including a list of the identified injuries and the diagnostic tests in 11:3-4.5(b). The materials shall include copies of the Care Paths or indicate how copies may be obtained;

3. A list of the medical procedures, treatments, diagnoses, diagnostic tests, durable medical equipment or other services that require precertification, if any;

4. An explanation of how the insurer will respond to decision point review/precertification requests, including time frames. The materials should indicate that:

i. Telephonic responses will be followed up with a written authorization, denial or request for more information within three business days;

5. An explanation of the insurer's option to require a physical examination pursuant to (e) below;

6. An explanation of the penalty co-payments imposed for the failure to submit decision point review/precertification requests where required in accordance with 11:3-4.4(e);

7. An explanation of the insurer's voluntary network or networks for certain types of testing, durable medical equipment or prescription drugs authorized by 11:3-4.8, if any;

8. An explanation of the alternatives available to the provider if reimbursement for a proposed treatment, diagnostic test or durable medical equipment is denied or modified, including insurer's internal appeal process and how to use it; and

9. An explanation of the insurer's restrictions on assignment of benefits, if any.

(e) A physical examination of the injured party shall be conducted as follows:

1. The insurer shall notify the injured person or his or her designee that a physical examination is required to determine the medical necessity of further treatment, diagnostic tests or durable medical equipment. An insurer shall include reasonable procedures for the notification of the injured person and the treating medical provider where reimbursement of further treatment, diagnostic testing or durable medical equipment will be denied for failure to appear at scheduled medical examinations.

2. The appointment for the physical examination shall be scheduled within seven calendar days of receipt of the notice in (e)1 above unless the injured person agrees to extend the time period.

3. The medical examination shall be conducted by a provider in the same discipline as the treating provider.

4. The medical examination shall be conducted at a location reasonably convenient to the injured person.

5. The injured person, upon the request of the insurer, shall provide medical records and other pertinent information to the provider conducting the medical examination. The requested records shall be provided at the time of the examination or before.

6. The insurer shall notify the injured person or his or her designee and the treating medical provider whether it will reimburse for further treatment, diagnostic tests or durable medical equipment as promptly as possible but in no case later than three business days after the examination. If the examining provider prepares a written report concerning the examination, the injured person or his or her designee shall be entitled to a copy upon request.

7. Insurers may include in their decision point review plan a procedure for the denial or reimbursement for treatment, diagnostic testing or durable medical equipment after repeated unexcused failure to attend a scheduled physical examination. The procedure shall provide for adequate notification of the insured and the treating provider of the consequences of failure to attend the examination.

(f) In administering decision point review and precertification, insurers shall avoid undue interruptions in a course of treatment. As part of their decision point review plans, insurers may include provisions that encourage providers to establish an agreed upon voluntary comprehensive treatment plan for all of a covered person's injuries to minimize the need for piecemeal review. An agreed comprehensive treatment plan may replace the requirements for notification to the insurer at decision points and for treatment, diagnostic testing or durable medical equipment requiring precertification. In addition, the insurer may provide that reimbursement for treatment, diagnostic tests or durable medical equipment consistent with the agreed plan will be made without review or audit.

(g) An insurer shall not retrospectively deny payment for treatment, diagnostic testing or durable medical equipment on the basis of medical necessity where a decision point review or precertification request for that treatment or testing was properly submitted to the insurer unless the request involved fraud or misrepresentation, as defined in 11:16-6.2, by the provider or the person receiving the treatment, diagnostic testing or durable medical equipment.

N.J. Admin. Code § 11:3-4.7

Amended by R.2000 d.454, effective 11/6/2000.
See: 31 N.J.R. 4210(a), 32 N.J.R. 4005(c).
Deleted a former (c); and recodified former (d) and (e) as (c) and (d).
Repeal and New Rule, R.2004 d.218, effective 6/7/2004 (operative October 27, 2004).
See: 35 N.J.R. 3072(a), 36 N.J.R. 2890(a), 36 N.J.R. 4319(a).
Section was "Decision point review".
Amended by R.2006 d.243, effective 7/3/2006.
See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c).
In (e)7, substituted "decision" for "description"; and in (g), substituted "N.J.A.C. 11:16-6.2" for "N.J.A.C. 11:16-16.2".
Amended by R.2009 d.190, effective 6/15/2009.
See: 41 N.J.R. 365(a), 41 N.J.R. 2486(a).
Rewrote (a)1.
Amended by R.2010 d.142, effective 7/6/2010.
See: 41 N.J.R. 2609(a), 42 N.J.R. 1385(a).
In the introductory paragraph of (a), substituted "(e), (f) and (g)" for "(d), (e) and (f)"; in (c)2, inserted the last sentence; in (c)3, deleted the last sentence; and in (d)6, updated the N.J.A.C. reference.
Administrative correction.
See: 42 N.J.R. 2129(a).
Amended by R.2012 d.187, effective 11/5/2012 (operative January 4, 2013).
See: 43 N.J.R. 1640(a), 44 N.J.R. 2652(c).
Rewrote (c)1; in (c)7, deleted "and" from the end; added new (c)8; recodified former (c)8 as (c)9; and in (d)1, substituted "numbers, e-mail addresses or through a website" for "numbers or email addresses".
Amended by R.2012 d.187, effective 11/5/2012 (operative November 5, 2016).
See: 43 N.J.R. 1640(a), 44 N.J.R. 2652(c), 45 N.J.R. 2392(a), 46 N.J.R. 2159(a), 47 N.J.R. 2673(a).
Rewrote (c)6.