N.J. Admin. Code § 11:3-5.4

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

Section 11:3-5.4 - Dispute resolution organizations

(a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria:

1. The dispute resolution organization shall not be owned or controlled by an insurer or affiliate of an insurer;

2. The dispute resolution organization shall utilize full-time dispute resolution professionals that meet the standards set forth in 11:3-5.5. For the purpose of this paragraph, "full-time" shall be construed to include persons who work fewer than five days per week, but who do not engage in other, conflicting employment;

3. The dispute resolution organization shall utilize an advisory council composed of parties who are users of the dispute resolution mechanism in connection with the selection of dispute resolution professionals and the periodic review of the organization's rules and processes;

4. The dispute resolution organization shall utilize procedures to avoid conflicts of interests as prohibited at 11:3-5.1 2;

5. The dispute resolution organization shall arrange for proceedings in locations reasonably convenient to the parties;

6. The dispute resolution organization shall maintain published rules for the conduct of the proceedings, and shall make them available to the parties and the public upon request;

7. The dispute resolution organization shall perform its functions in a prompt and efficient manner, giving due regard to the nature of the proceeding and the need for special attention when required by the exigencies of a particular matter; and

8. The dispute resolution organization shall provide sufficient oversight and training of its dispute resolution professionals so as to promote fair, efficient and consistent determinations consistent with substantive law and with rules adopted by the Commissioner.

(b) The dispute resolution organization shall develop and maintain a dispute resolution plan approved by the Commissioner that sets forth its procedures and rules. The dispute resolution plan shall be reviewed at least annually and revisions made upon approval by the Commissioner. The plan shall include the following elements:

1. The plan shall provide that PIP dispute resolution be initiated by written notice to the administrator and to all other parties of the party's demand for dispute resolution, which notice shall set forth concisely the claims, and where appropriate the defenses, in dispute and the relief sought. Where the arbitration is filed by a provider acting as an assignee of benefits or with a power of attorney from the insured, the notice shall include proof of compliance with the internal appeal process required by N.J.A.C. 11:3-4.7B. All notices shall also include such other information as may be required for administrative purposes;

2. The plan shall provide for consolidation of claims into a single proceeding where appropriate in order to promote prompt, efficient resolution of PIP disputes consistent with fairness and due process of law;

3. The plan shall provide the assigned dispute resolution professional with sufficient authority to provide all relief and to determine all claims arising under PIP coverage, but may provide for limited, procedural or emergent matters to be determined by one or more specially designated dispute resolution professionals;

i. Emergent or expedited relief shall be granted upon demonstration that immediate and irreparable loss or damage will result in the absence of such relief;

4. The plan shall provide for the assignment of a medical review organization to review the case and report its determination when requested pursuant to 39:6A-5.2 and this subchapter;

5. The plan shall provide for the prompt, fair and efficient resolution of PIP disputes, including in-person and on-the-papers proceedings in accordance with the rules of the dispute resolution organization. The plan shall also provide that alternate procedures may be utilized when appropriate, which may include mediation, conferences to promote consensual resolution and expedited hearings upon receipt of a medical review organization report, consistent with principles of substantive law and rules adopted by the Commissioner;

6. The plan shall provide for a procedure whereby a demand for arbitration based on an insurer's denial of a decision point review or precertification request as not medically necessary, as defined in 11:3-4.2, may be submitted directly to an MRO for an expedited determination of medical necessity. No DRP will be assigned and no attorney fees may be charged. The administrator shall set a fee for handling such requests in addition to the MRO fee. The plan shall provide that if the expedited MRO review does not resolve the dispute, the claimant/insured may continue with the standard arbitration procedure before a DRP; and

7. The plan shall provide for the fair and efficient conduct of adversarial proceedings when other methods of dispute resolution are either unsuccessful or inappropriate, consistent with traditional notions of due process and fundamental fairness. It shall address, at least, the following procedural issues;

i. Discovery;

ii. Receipt of evidence by the dispute resolution professional;

iii. Submission of briefs or memoranda of law and fact;

iv. Provision for decisions without testimony on consent of parties;

v. Notice and place of hearing;

vi. Methods to request adjournments;

vii. Presentation of testimony and evidence at a hearing; and

viii. Supplementation of the record.

(c) If consistent with its dispute resolution plan, a dispute resolution organization may utilize one or more dispute resolution professionals specifically to handle preliminary matters on actions including motions to disqualify an appointed DRP.

N.J. Admin. Code § 11:3-5.4

Amended by R.2010 d.142, effective 7/6/2010.
See: 41 N.J.R. 2609(a), 42 N.J.R. 1385(a).
Added (b)3i; in (b)5, deleted "and" from the end; added new (b)6; and recodified former (b)6 as (b)7.
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 (b)1 and (b)5; and in the introductory paragraph of (b)7, substituted "proceedings" for "hearings".