N.J. Admin. Code § 11:3-4.7A

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

Section 11:3-4.7A - PIP vendor registration requirements

(a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section.

(b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file for registration by February 3, 2013.

(c) Application for registration shall be made on a form prescribed by the Commissioner, which can be found on the Department's website at http://www.state.nj.us/dobi/pipinfo/aicrapg.htm.

(d) The application shall be accompanied by the applicant's business plan, which shall include the following information:

1. A statement generally describing the applicant, its facilities, personnel, and the services to be offered by the PIP vendor;

2. The name of its medical director(s) licensed to practice as physician(s) in New Jersey and a detailed explanation about how the medical director(s) provide(s) oversight of determinations of medical necessity;

3. The name and contact information of a person at the vendor who is designated to receive and handle complaints and inquiries from the Department;

4. Information on activities undertaken or to be undertaken in New Jersey by the company;

5. A demonstration of the applicant's capability to provide a sufficient number of experienced and qualified personnel in the areas of PIP utilization management, and information on staffing levels, including, but not limited to, training, hiring requirements, experience of staff in general and with PIP utilization management in particular;

6. A statement about whether the applicant is licensed or certified as an entity that has networks as that term is defined in 11:3-4.8(a) or accredited by nationally recognized accrediting agencies such as URAC (http://www.urac.org/) in Health Utilization Management; and

7. A copy of the applicant's certificate of incorporation.

(e) The application shall also be accompanied by the following information concerning how the applicant will handle PIP utilization management:

1. The vendor's clinical review criteria and protocols. The information shall include a descriptive flow chart of its processes used in decision-making, which shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers, and be based upon generally accepted medical standards and standard professional treatment protocols;

2. A copy of the vendor's policies and procedures that demonstrate that the vendor is handling utilization management in accordance with N.J.A.C. 11:3-4, 5 and 29; and

3. The mechanisms it uses to detect underutilization and overutilization of services.

(f) A PIP vendor that arranges the physical examinations of injured parties pursuant to 11:3-4.7(e) shall submit the criteria it uses to select providers to be on the vendor's panel of examining providers, how it evaluates the quality of an examining provider's examination report and how it avoids conflicts of interest when examinations are ordered and scheduled.

(g) Two copies of the information in (a) through (f) above shall be submitted to the Department at the following address: New Jersey Department of Banking and Insurance

Office of Property and Casualty

P.O. Box 325

Trenton, NJ 08625-0325

(h) The Department shall advise the applicant if the application is incomplete not later than 60 days after receipt of the application. Notice to the applicant that the application is incomplete shall specify the missing items or information. The Department shall disapprove an incomplete application if the requested information is not provided within 30 days of the notification to the applicant. If the Department does not notify the applicant of missing items or information within 60 days of receipt, the application shall be deemed complete.

(i) The Commissioner shall approve an application for registration if he or she finds that the applicant has demonstrated the ability to perform services in a manner that meets the requirements of this subchapter.

(j) The Commissioner may deny an application for registration as a PIP vendor if he or she finds that any of standards established by this subchapter have not been met or for any other reasonable grounds.

1. If the application for registration is denied, the Commissioner shall notify the applicant in writing of the reasons for the denial.

2. When the Department denies an application for registration, the applicant may request a hearing within 30 days of receipt of the denial by submitting a request in writing to the address in (g) above setting forth, with specificity, the reasons that the applicant disputes the Department's denial notice.

(k) Registration shall be effective for a period of two years. Registered PIP vendors shall reapply for registration 90 days prior to expiration by submitting the information in (d) through (f) above showing changes to the items previously submitted.

(l) All data or information in the PIP vendor's application for registration and the vendor's contract with the insurer required to be submitted pursuant to 11:3-4.7(c)1 shall be confidential and shall not be disclosed to the public, except as follows:

1. The PIP vendor's certificate of incorporation;

2. The PIP vendor's address;

3. The names of the PIP vendor's officers and directors, or the individuals in the organization responsible for the administration of utilization management including the medical director(s); and

4. The date of registration of the PIP vendor and date that registration expires.

(m) The Commissioner may suspend or revoke the registration of a PIP vendor upon finding that the PIP vendor no longer meets the standards set forth in this subchapter; that PIP utilization review services are not being provided in accordance with the requirements of this subchapter; or that the registration was granted based on false or misleading information.

1. Proceedings to revoke or suspend the registration shall be conducted pursuant to N.J.A.C. 11:17D.

2. Upon request of the PIP vendor for a hearing, the matter shall be transferred to the Office of Administrative Law for a hearing conducted pursuant to the Administratve Procedure Act, 52:14B-1 et seq. and 52:14F-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

N.J. Admin. Code § 11:3-4.7A

New Rule, 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).