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.