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NEWJERSEYADMINISTRATIVECODETITLE11.
DEPARTMENTOFBANKINGANDINSURANCEDIVISIONOFINSURANCECHAPTER3.
AUTOMOBILEINSURANCESUBCHAPTER25.
PRIVATEPASSENGERAUTOMOBILEINSURANCE:NOTIFICATIONBYTREATINGHEALTHCAREPROVIDERS(Fulltextofruleeffective6/7/04)11:3-25.
1Purposeandscope(a)ThepurposeofthissubchapteristoimplementN.
J.
S.
A.
39:6A-5,asamendedbyP.
L.
1995,c.
407,byestablishingprocedurestobefollowedbytreatingmedicalproviderstogivetimelynotificationofthecommencementofmedicaltreatmentforinjuriessustainedinautomobileaccidents.
Thesubchaptersetsforth:1.
TimelimitsforthefilingofnotificationofthecommencementoftreatmentforPIPclaims;2.
Theactionstobetakenuponfailuretocomplywiththenotificationtimelimits,includingreductionordenialofclaimpayments;3.
Thefactorstobeconsideredinevaluationofalatenotification;and4.
Therightsofproviderswhenpaymentisreducedordeniedforfailuretocomplywiththenotificationrequirements.
(b)ThissubchaptershallapplytoeveryinsurerauthorizedtotransactthebusinessofautomobileinsuranceinthisState.
ThesubchapterappliestotreatmentforinjuriesresultingfromautomobileaccidentsthatoccurafterJuly8,1996.
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2DefinitionsThefollowingwordsandterms,whenusedinthissubchapter,shallhavethefollowingmeanings,unlessthecontextclearlyindicatesotherwise.
"Coveragestatus"meansthestatusofPIPcoverageforaninjuredpartypursuanttoN.
J.
S.
A.
39:6A-5.
"Department"meanstheDepartmentofBankingandInsuranceoftheStateofNewJersey.
"Eligiblecharge"meansthetreatingmedicalprovider'susual,customaryandreasonablechargeortheupperlimitonthemedicalfeescheduleasfoundinN.
J.
A.
C.
11:3-29.
6,whicheverislowersubjecttoprovisionsofN.
J.
A.
C.
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4.
"Emergencycare"meansallmedicallynecessarytreatmentofatraumaticinjuryoramedicalconditionmanifestingitselfbyacutesymptomsofsufficientseverity(includingseverepain,psychiatricdisturbanceand/orsymptomsofsubstanceabuse)suchthatabsenceofimmediateattentioncouldreasonablybeexpectedtoresultin:death;seriousimpairmenttobodilyfunctions;orseriousdysfunctionofabodilyorganorpart.
Suchemergencycareshallincludeallnecessarycareimmediatelyfollowinganautomobileaccident,including,butnotlimitedto,immediatepre-hospitalcare,transportationtoahospitalortraumacenter,emergencyroomcare,surgery,criticalandacutecare.
Emergencycareextendsduringtheperiodofinitialhospitalizationuntilthepatientisdischargedfromacutecarebytheattendingphysician.
"Multipletreatingmedicalprovider"meansatreatinghealthcareproviderasdefinedhereinthatprovidesemergencycare,inassociationwithoneormoreothertreatingmedicalproviders.
"Notification"or"notice"meansawrittencommunication,transmittedbymail,facsimileorelectronicmessage("E-mail").
"Personalinjuryprotection"or"PIP"meansthecoveragesetforthatN.
J.
S.
A.
39:6A-4or39:6A-3.
1ortheemergencypersonalinjuryprotectioncoverageprovidedbyaSpecialAutomobileInsurancePolicypursuanttosection45ofP.
L.
2003,c.
89.
.
"PIPinformation"means:thenameandaddressoftheinsuredandthenameandaddressoftheinjuredparty,ifdifferent;thenameofthePIPinsurerandtheaddressestablishedbytheinsurerfornotificationofcommencementofmedicaltreatmentpursuanttoN.
J.
A.
C.
11:3-25.
3(c);thepolicynumberoftheinsurancepolicyprovidingPIPbenefits;andthedateoftheaccident/injury.
Atreatingmedicalprovidermayobtainthisinformationfromtheinsured,theinjuredparty,thehospital,apolicereportoranyotherreasonablyavailablesource.
"Secondarymedicalproviders"meansthosehealthcareproviderswhoprovidemedicalproducts,careandservicestoapersoninjuredinanautomobileaccidentonlyafterhavingreceivedaprescriptionfromatreatinghealthcareprovider.
Secondarymedicalprovidersshallinclude,butarenotlimitedto,pharmacists,visitingnurses,prostheticsfabricatorsandprovidersofdurablemedicalequipmentproducts.
Notwithstandingtheexistenceofaprescriptionofatreatingmedicalprovider,physicaltherapists,chiropractorsandanysecondarymedicalproviderwhoseekspaymentofaneligiblechargeinexcessof$500.
00forindividualservicesorproductsprovidedononeoccasionorinthecourseof30daysshallnotbeconsideredsecondarymedicalproviders.
"Treatinghealthcareprovider"meansthosepersonslicensedorcertifiedtoperformhealthcaretreatmentorservicescompensableasmedicalexpensesandshallinclude,butnotbelimitedto:1.
Ahospitalorhealthcarefacilitywhichismaintainedbyastateoranyofitspoliticalsubdivisions;2.
AhospitalorhealthcarefacilitylicensedbytheDepartmentofHealthandSeniorServices;3.
OtherhospitalsorhealthcarefacilitiesdesignatedbytheDepartmentofHealthandSeniorServicestoprovidehealthcareservices,orotherfacilities,includingfacilitiesforradiologyanddiagnostictesting,freestandingemergencyclinicsoroffices,andprivatetreatmentcenters;4.
Anonprofitvoluntaryvisitingnurseorganizationprovidinghealthcareservicesotherthaninahospital;5.
Hospitalsorotherhealthcarefacilitiesortreatmentcenterslocatedinotherstatesornations;6.
Physicianslicensedtopracticemedicineandsurgery;7.
Licensedchiropractors;8.
Licenseddentists;9.
Licensedoptometrists;10.
Licensedpharmacists;11.
Licensedchiropodists(podiatrists);12.
Registeredbio-analyticallaboratories;13.
Licensedpsychologists;14.
Licensedphysicaltherapists;15.
Certifiednurse-midwives;16.
Certifiednurse-practitioners/clinicalnurse-specialists;17.
Licensedhealthmaintenanceorganizations;18.
Licensedorthotistsandprosthetists;19.
Licensedprofessionalnurses;20.
Licensedoccupationaltherapists;21.
Licensedspeech-languagepathologists;22.
Licensedaudiologists;23.
Licensedphysicianassistants;24.
Licensedphysicaltherapistsassistants;25.
Licensedoccupationaltherapyassistants;and26.
Providersofotherhealthcareservicesorsupplies,includingdurablemedicalgoods.
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3Notificationofcommencementoftreatment(a)WhenmedicaltreatmentisrenderedforwhichaclaimforpaymentwillbemadepursuanttothePIPcoverageofaprivatepassengerautomobileinsurancepolicy,atreatinghealthcareprovidershallprovidenoticetothePIPinsurernolaterthan21daysfollowingthedateofthecommencementofsuchtreatment.
(b)InaccordancewiththePIPinformationprovidedbytheinjuredpartyortheinsured,noticeshallbesentbythetreatinghealthcareprovidertotheinsurerattheaddressestablishedbytheinsurerforthereceiptofsuchnotice.
(c)Insurersshallestablishoneaddresswherenoticemustbesentbytreatinghealthcareproviderspursuanttotheserules.
Insurersshallprovidethisaddress,andmayprovideafacsimiletransmissionnumber,andE-mailaddressifany,onallinsuranceidentificationcardsissuedbytheinsurerafterJanuary6,1997.
(d)InaccordancewiththeprovisionsofN.
J.
A.
C.
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10,insurersshallfilewiththeDepartmenttheaddress,andmayprovideafacsimiletransmissionnumber,andE-mailaddress,ifany,wherenoticeofcommencementoftreatmentshouldbesent.
Insurersshallalsoincludethenameandtelephonenumberofacontactpersonattheinsurerforthispurpose.
SuchinformationshallbeaddedtoalistofinsureraddressesmaintainedbytheDepartment.
(e)NoticesenttotheaddressprintedonavalidinsuranceidentificationcardorontheDepartment'scurrentlistofaddressesshallbepresumedtohavebeensenttotheproperaddress.
(f)Within14daysafterreceivingnoticeofthecommencementoftreatment,theinsurershallnotifythetreatinghealthcareproviderofthecoveragestatusofthepersonreceivingtreatment.
Ifthenoticefromtheinsurerstatesthatthecoveragestatusofthepersonreceivingtreatmentisunknown,theinsurershallmakeadeterminationofcoverageandprovidewrittenconfirmationtothetreatinghealthcareprovidernolaterthan60daysfromreceiptofnoticeofcommencementoftreatment.
Exampleswherethecoveragestatusmaynotbeknownarewhentheinjuredpersonisnotanamedinsured,principaloroccasionaloperator,orisnototherwiselistedasaresidentoftheinsuredhouseholdonthemostrecentinformationprovidedtotheinsurerbythenamedinsured.
(g)Thenoticerequirementssetforthin(a)through(c)aboveandtheeligiblechargereductionscontainedinN.
J.
A.
C.
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5shallnotapplytosecondarymedicalproviders,exceptasnotedinthedefinitionofthattermfoundinN.
J.
A.
C.
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2.
(h)Incalculatingthetimefornoticein(a)and(f)above,thedaytreatmentbeginsorthedaytheinsurerreceivesnoticefromthetreatinghealthcareproviderisnottobeincluded.
IfthelastdayforprovidingnoticefallsonaSaturday,Sundayorlegalholiday,thetimerunstothenextbusinessday.
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4Contentofnoticeandproofofreceipt(a)ThetreatinghealthcareprovidershallsendthewrittennoticerequiredbyN.
J.
A.
C.
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3(a)tothePIPinsureroneither:1.
The"NotificationofCommencementofMedicalTreatmentForm"foundinAppendixA,appendedtoandincorporatedbyreferenceinthissubchapter;or2.
Abillorinvoicerenderedbythetreatinghealthcareproviderthatincludesataminimumtheinformationrequiredinthe"NotificationofCommencementofMedicalTreatmentForm"inAppendixA.
(b)Whenanynoticerequiredbythissubchapterismailed,thepostmarkshallbetheproofofmailing.
TheinsurershallretainevidenceofuntimelymailingofthenoticewheneveritdeniesorreducespaymentpursuanttoN.
J.
A.
C.
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5.
(c)InthosecaseswherefacsimileorE-mailnoticeisauthorizedbytheinsurerwhenanynoticerequiredbythissubchapterissentbyfacsimileorbyE-mail,theproofofnoticeshallbethefacsimiletransmissionreceiptgeneratedbythesender'sfacsimilemachine,acopyoftheE-mailmessageshowingthedateandtimeoftransmittaloranacknowledgmentofreceiptgeneratedbythereceivingsystem.
Nothinginthissectionshallprohibittreatinghealthcareprovidersandinsurersfrommutuallyagreeingtoacceptotherproofsofnoticeforelectronictransmissions.
Itshallbetheresponsibilityofthetreatinghealthcareprovidertoretainproofofnoticeofcommencementoftreatmenttransmittedbyfacsimileorotherelectronicmeans.
(d)AnynoticegivenpursuanttothissubchaptershallbedeemedtohavebeenmadeonthedateofpostmarkorthedateoftransmissioninthecaseoffacsimiletransmissionandE-mail.
(e)Whenabillorinvoiceisusedtoprovidenoticeofthecommencementoftreatmentinaccordancewiththissubchapter,itshallnotbedeemedtoconstitutenoticeunlessthefollowingmessageappearsonthefirstpageofthebillorinvoice:"21DAYNOTICE"or"FIRSTBILL21DAYNOTICE.
"Thismessageshallbeincontrastingcolorinkandbeinatleast12pointcapitalletters.
Useofarubberstamporaffixedlabelisacceptableforpurposesofcomplyingwiththissubsection.
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5Latenotification(a)Intheeventnoticeofcommencementofmedicaltreatmentismadeafter21days,theinsurershalladvisethetreatinghealthcareproviderinwritingofthelatenotificationandmayreservetherighttoreducepaymentinaccordancewith(b)below.
(b)Wherenoticeofthecommencementofmedicaltreatmentisnottimelyprovidedinaccordancewiththissubchapter,aninsurermayapplythefollowingreductionstotheeligiblecharges:1.
22to30daysafterthecommencementoftreatment:10percentreduction.
2.
31to60daysafterthecommencementoftreatment:25percentreduction.
3.
61to120daysafterthecommencementoftreatment:50percentreduction.
4.
121to160daysafterthecommencementoftreatment:75percentreduction.
5.
161ormoredaysfromthecommencementoftreatment:100percentreduction.
(c)Ifnoticeisnotprovidedasrequiredbythissubchapter,thereductionformulasetforthin(b)aboveshallapplytoalleligiblechargesforwhichthetreatinghealthcareproviderseekspaymentthroughsuchlatenotice.
(d)Insurersshallnotreduceaneligiblechargeunderthefollowingcircumstances:1.
WhentheproviderisamemberofthegroupofmultipletreatinghealthcareprovidersgivingemergencycareduringtheinitialhospitalizationasdefinedinN.
J.
A.
C.
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2;2.
WhentheproviderisasecondarymedicalproviderasdefinedinN.
J.
A.
C.
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2;3.
Whenthemedicalconditionoftheinjuredpartymadeitimpossibletocomplywiththenoticerequirement;or4.
Whentheproviderhassubmittedarequestfordecisionpointrevieworprecertificationoftreatmentortestinginaccordancewithaninsurer'sdecisionpointreviewplanapprovedinaccordancewithN.
J.
A.
C.
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6Standardsforadjustmentofreduction(a)NotwithstandingthereductionssetforthinN.
J.
A.
C.
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5(b),insurersmaychoosetopaythefulloralessreducedamountofaneligiblechargebaseduponconsiderationofthefollowingfactors:1.
Whetherthetreatinghealthcareproviderhaspreviouslyprovideduntimelynoticeunderthissubchapterorhasestablishedapatternofuntimelynotice;2.
Thecostofmedicaltreatmentprovidedbythetreatinghealthcareproviderbetweenthetimetreatmentcommenced,whennoticewasdueandwhenitwasprovided;3.
TheinjuredpartywasapedestrianwhodidnothavePIPcoverageasthenamedinsuredorresidentrelativeunderanotherpolicyandthecircumstancesaresuchthatadditionaltimeisnecessarytoidentifythepolicyunderwhichcoverageisbeingprovided;4.
Anypotentialadverseimpactonthepublic;and5.
Suchotherfactorsastheinsurermaydetermine.
(b)Within60daysofreceiptofnotice,orsuchadditionaltimeasmaybeaffordedunderN.
J.
S.
A.
39:6A-5g,theinsurershallgivethetreatinghealthcareprovidernoticeofitsfinaldeterminationastopayment,reductionordenialofpaymentofaneligiblecharge.
Suchnoticeshallbeclearlylabeled"FinalDetermination,"anditshallreferclearlytotheinjuredparty,theinsured,theclaimnumber,thedateofaccident,thedateoffirsttreatment,thedatenoticeofthecommencementoftreatmentwasmadeandtheacceptanceorrejectionofanyofthestandardsofadjustmentofthereductionin(a)aboveandN.
J.
A.
C.
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5(b).
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7ResponsibilityforpaymentWheneveraneligiblechargehasbeenreducedordeniedpursuanttoN.
J.
A.
C.
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5(b),thetreatinghealthcareprovidershallnotseektoobtainpaymentdirectlyfromtheinsuredorthepersonreceivingtreatment.
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8ProcedureforappealsAtreatinghealthcareproviderwhofailstonotifytheinsurerwithin21daysandwhoseclaimhasbeenreducedordeniedbytheinsurerpursuanttoN.
J.
A.
C.
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5(b)may,inthediscretionofajudgeofSuperiorCourt,bepermittedtorefilesuchclaimprovidedthattheinsurerhasnotbeensubstantiallyprejudicedthereby.
Applicationtothecourtforpermissiontorefileaclaimshallbemadewithin14daysofthereceiptoftheinsurer'sfinaldeterminationofreductionordenialofpaymentandshallbemadeuponmotionbaseduponaffidavitsshowingsufficientreasonsforthefailuretonotifytheinsurerwithin21daysofthecommencementoftreatment.
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9Reportingrequirement(a)ByFebruary5,1997,everyinsurershallfilewiththeDepartmenttheaddress,facsimilenumber(ifnoticebyfacsimileispermitted)andE-mailaddress,ifany,ofthedesignatedlocationforthefilingofnoticerequiredunderthissubchapter.
InsurersshalluseAppendixB,appendedtoandincorporatedbyreferenceinthissubchapter,toreporttheinformationrequiredbythissubsection.
(b)InsurersshallcompleteandfiletheinformationinAppendixBbyJanuary1ofeachyear.
(c)CompletedcopiesofAppendixBshallbesubmittedto:DepartmentofBankingandInsuranceDirectorofPublicAffairsPOBox325Trenton,NewJersey08625-032511:3-25.
10ComplianceFortreatmentsrenderedbetweenJanuary6,1997andJuly6,1997,alleligiblechargereductionssetforthinN.
J.
A.
C.
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5(b)shallbereducedby50percent(forexample,a10percentreductionshallbefivepercent,a25percentreductionshallbe12.
5percent,etc.
).