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On or After 4/17/17 Internal appeal process

New administrative rule NJAC 11:3-4.7B goes becomes operational on 4/17/17.

  • NJAC 11:3-4.7B deals with the Uniform Internal Appeal process.
  • An Arbitration CANNOT BE FILED without completing the internal appeal process. We anticipate that Forthright will be creating its own rule asking for internal appeals prior to filing arbitration demands.
  • The insurance carriers will be issuing new Decision Point Revie Plan (“DPRP”) which you must review to ensure you have the proper fax numbers and understand each carriers specific requirement.
  • Appeals can only be done using the hyperlinked DOBI forms below.
  • The central rule is that each issue shall only be required to receive one internal appeal review by the insurer prior to arbitration.
  • There will be two types
  1. Uniform PIP Pre- Service Appeal Formdealing with appeals of DPRP and/or pre-certification denials or modifications before performing or issuing the service or providing the durable medical equipment.
    1. It must be submitted no later than 30 days after receipt of the denial or modification of the requested service
    2. The issuer has 14 days after the receipt of the pre-service appeal to respond.
  2. Uniform PIP Post-Service Appeal Form: for appeals after the performance or issuing the services.
    1. MUST be submitted at least 45 days prior to initiating arbitration or filing an action in Superior Court.
    2. The insurer has 30 days from the receipt of the post service appeal to respond.

Key: Please make sure ALL your appeals include supporting documentation. We anticipate the insurers will be attacking the sufficiency of documentation submitted during the internal appeal phase. Thus, we would like all providers to submit ALL treatment records that support your position on the specific issue being appealed along with a brief explanation letter to the carrier.

Visit the 3 major approved NJ Auto-Vendors to obtain DPRP (click to the specific vendor and locate the specific carrier):

  • Prizm (currently a vendor for the following carriers: Amica Insurance; CountryWay; GEICO Insurance(prior to 10/1/2012 only); IDS Property Casualty Insurance Company (Ameriprise); MAPFRE Insurance; Mercury Insurance; MetLife).
  • CSG (currently a vendor for the following carriers: 21st Century Insurance, CSAA Insurance Group (AAA Midatlantic); American Millenium Insurance; Bristol West; CURE; Electric Insurance; Farmers Insurnace; First Nonprofit Ins.; Hanover; Hortica Insurance; Foremost Insurance; Liberty Mutual Insurance; Norfolk&Deham; Personal Service Insurance; Selective Insurance; State Farm Insurance; and, United Fire Group Insurance).
  • Procura Inc (currently a vendor for the following carriers: (Allstate Insurance; AutoOne; Esurance; Farm Family; IFA; Integon Insurance; Knightbrook; MIC General Insurance; NL&G; Uticae among others).