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NJ PIP UPDATE: Implementation of the Internal Appeal Rule on 4/17/17 FAQs

Q: How will the April 17, 2017 operative date of the new internal appeals rule be implemented? A: The Department believes that the rule should apply to pre-service and post-service appeals that are submitted on or after April 17, 2017. This would result in all appeals being handled consistently in accordance with the regulation from 04/17/2017 going forward. This will be less confusing for providers and insurers and is consistent with how the effective date of other changes to DPR plans have been handled by the Department. Q: The Internal Appeal Procedures rules does not state how the appeal forms are to be transmitted to the insurer by the appealing party. There is no space on the form to indicate if the form should be submitted to the insurer or the insurer’s PIP vendor. A: The information on where and how the internal appeal forms shall be transmitted to the insurer will be contained in the insurer’s Decision Point Review plan. Q: If the provider fails to complete the form in its entirety, can the insurer deny the appeal request administratively? A: The insurer’s requirement concerning administrative denials should be contained in the insurer’s Decision Point Review plan. Read more at...

FAQS regarding the “REVISED” 2016 Uniform Attending Provider Treatment Plan (“APTP”)

Effective February 9, 2016, the revised Attending Provider Treatment Plan form shall be used by all Providers to submit Decision Point Review and Pre-certification Requests. To obtain a copy of this form, click on this link. Can the Uniform Attending Provider Form be submitted by a DME provider with a note from the treating physician or chiropractor concerning the medical necessity of the equipment? Although a DME vendor is defined as a provider in N.J.A.C. 11:3-4, it was not the intention of the Department that DME vendors submit the Uniform Attending Provider Form to payors. DME vendors don’t treat patients or make diagnoses. The attending provider needs to set forth the diagnosis(es) and clinically supported findings on the Uniform Attending Provider Treatment Form and sign the form with its Statement and Fraud Prevention Warning. The DME vendor or other non-treating provider can then provide the equipment or services that have been determined to be medically necessary. No spaces on the form are provided for co-morbidities/treatment complications that are relevant to a Decision Point Review or Precertification request. How should this be handled by providers? The Uniform Attending Provider Form is not intended to include ALL the information that is submitted with a Decision Point Review or Precertification request. It should be accompanied by SOAP notes, test results and other information related to the request, including how co-morbidities or treatment complications that affect the treatment or testing requested. READ...

FAQs concerning the ICD-10 Conversion and PIP

Question: Are services billed under the Personal Injury Protection (PIP) Medical Expense benefit coverage subject to the requirement that only ICD-10 diagnosis codes be used after October 1, 2015? Answer: No. The conversion to ICD-10 codes is mandatory for all providers and payors subject to the Health Insurance Portability Accountability Act (HIPAA). Personal Injury Protection (PIP) Medical Expense benefit claims made under auto insurance policies are not subject to HIPAA. However, employer health plans, Medicare and Medicaid are subject to HIPAA and they comprise the vast majority of medical services in the United States. The Department expects that providers, automobile insurers and PIP vendors have already started the process to transition to ICD-10. Read...

CHANGES IN CODING SYSTEM: FULL COMPLIANCE REQUIRED FOR ICD-10 BY OCTOBER 1, 2015.

The United States Department of Health and Human Services (HHS) ruled on 7/31/14 that ICD-10-CM and ICD-10-PCS will be implemented into the HIPAA mandated code set on October 1, 2015. This will make the US coding set in compliance with the coding schemes of the rest of the world. As such, you must prepare accordingly. On or after 10/1/15: MUST comply with the ICD-10. Failure to comply means the claims will not be processed. Before 10/1/15: claims for services and in patient procedures provided before the compliance date must use IDC-9 codes. According to HHS/CMS, ICD-10 applies to everyone covered under HIPPA. What should providers do to prepare for the transition to ICD-10? Providers should plan to test their ICD-10 systems early, to help ensure compliance. Beginning steps in the testing phase include: > Internal testing of ICD-10 systems > Coordination with payers to assess readiness > Project plan launch by data management and IT teams             For providers who have not yet started to transition to ICD-10, below are       actions steps to take now: > Develop an implementation plan and communicate the new system changes to your organization, your business plan, and ensure that leadership and staff understand the extent of the effort the ICD-10 transition requires. > Secure a budget that accounts for software upgrades/software license costs, hardware procurement, staff training costs, work flow changes during and after implementation, and contingency planning. > Talk with your payers, billing and IT staff, and vendors to confirm their readiness status. > Coordinate your ICD-10 transition plans among your partners and evaluate contracts with payers and vendors for policy revisions,...

F.A.Q on Examination Under Oath (“EUO”)

What is an Examination under Oath? An Examination under Oath or EUO is a sworn statement given by someone who has made a claim due to car accident. The statement is usually requested by the carrier and is taken under oath. The statements are recorded by a court reporter with a transcript made available at a later time. Does the carrier have a right to demand EUO of the patient? The basis for the right to examine an insured is the insurance policy. The insurance policy defines the rights and duties for the parties. Included in most carriers’ policy is a notice that the insured (“persons seeking coverage under its policy”) might be required to submit to an EUO. What types of questions are involved in the EUOs? EUOs could be requested for questions involving coverage; eligibility; medical necessity of continued treatment; details on the accident; allegations of fraud; confirmation of address; etc. Can a claim be denied for failure to attend an EUO? Yes, most carriers’ plan denotes that failure to attend two scheduled EUOs results in a termination of benefits. Most carriers typically assert the defense of “failure to cooperate.” According to the case law, the alleged non-cooperation must be egregious (N.J.A.F.I.U.A. v Jallah, 256 NJ Super. 134 [App. Div. 1992]) and the carrier must show appreciable prejudice (Hager v. Gonsalves, 398 N.J. Super. 529, 534 [App. Div. 2008]) in order to exhibit such draconian remedy of denying the claim based on a failure to attend EUO. What should I do once I (patient) get an EUO notice? As a patient, you should immediately communicate with your counsel. What...