SUPERIOR COURT OF NEW JERSEY 

 APPELLATE DIVISION 

 DOCKET NO. A-0486-22 

PRINCETON NEUROLOGICAL 

SURGERY, P.C., 

 Plaintiff-Appellant, 

v.

HORIZON BLUE CROSS BLUE 

SHIELD OF NEW JERSEY, 

 Defendant-Respondent. 

_____________________________

Submitted January 8, 2024 – Decided January 17, 2024 

Before Judges Mawla and Marczyk. 

On appeal from the Superior Court of New Jersey, Law 

Division, Mercer County, Docket No. L-0796-19.

Buttaci Leardi & Werner, LLC, attorneys for appellant 

(John W. Leardi and Nicole Patricia Allocca, on the

briefs). 

Stradley Ronon Stevens & Young, LLP, attorneys for 

respondent (Adam J. Petitt, of counsel; Robert J. 

Norcia, on the brief). 

PER CURIAM 

NOT FOR PUBLICATION WITHOUT THE 

APPROVAL OF THE APPELLATE DIVISION 

This opinion shall not "constitute precedent or be binding upon any court." Although it is posted on the 

internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.
2 A-0486-22

 Plaintiff Princeton Neurological Surgery, P.C. (PNS) appeals from: an 

August 16, 2019 order dismissing its claims against defendant Horizon Blue 

Cross Blue Shield (Horizon) for lack of subject matter jurisdiction and failure 

to state a claim; a November 15, 2019 order denying PNS's motion to amend its 

complaint; and six September 2, 2022 orders granting Horizon's motion for 

summary judgment and other relief dismissing PNS's common law claims. We 

affirm. 

 PNS is a neurological surgery practice that is an out-of-network provider 

with Horizon and has no contractual fee agreement when it treats Horizon's 

beneficiaries in exchange for participating in Horizon's managed care network. 

Between 2014 and 2017, PNS made insurance verification calls to Horizon 

before treating Horizon-insured patients: D.A., K.C., J.C., D.C., M.G., D.K., 

T.M., P.M., B.M., and D.R.1 

According to PNS's complaint, during each call, PNS disclosed the 

procedure it intended to perform and each patient's insurance information to 

Horizon. PNS "verified the amount of benefits payable for each service by 

requesting . . . the reimbursement methodology for out-of-network services, the 

applicable patient cost sharing under each plan, including deductibles, co1

 We use initials pursuant to Rule 1:38-3(a)(2). 
3 A-0486-22

payments, and/or co-insurance, and also the annual out-of-pocket maximum . . . 

under each patient's [p]lan." Horizon verified PNS was eligible for payment 

"based on a specific percentile of the [FAIR] Health

[2] guidelines" as an out-ofnetwork provider. 

PNS's complaint noted it understood the "verification of [p]lan benefits" 

was "not . . . a guaranty of payment." Indeed, during every verification call 

placed to Horizon, there was a recorded disclaimer the representations made 

during the call were not a guaranty of payment. A PNS employee confirmed 

this fact during her deposition. Furthermore, PNS's complaint acknowledged it 

knew "there are items outside of eligibility that affect reimbursement [such as] 

medical necessity." PNS performed the surgeries on the Horizon-insured 

patients after the verification calls. 

FAIR Health is used to calculate benchmark healthcare charges based on 

an aggregate dataset of actual charges for medical treatment and procedures, 

organized by geographic location, and arranged from lowest to highest costs, 

2

 "FAIR Health is an independent nonprofit that collects data for and manages 

the nation's largest database of privately billed health insurance claims and is 

entrusted with Medicare Parts A, B and D claims data for 2013 to the present." 

FAIR Health, https://www.fairhealth.org/about-us (last visited Jan. 9, 2024). 
4 A-0486-22

broken into percentiles.3 It provides a fee estimator, which allows providers to 

view the benchmark charge data "in distinct geographic areas, called geozips, 

which are generally identified by the first three digits of a zip code." 4 Another 

methodology for calculating benchmark charges is the Prevailing Healthcare 

Charges System (PHCS) database. 

 After performing the surgeries, PNS billed Horizon. The bills for each 

patient and Horizon's payments were detailed in PNS's complaint as follows: 

A. [PNS] submitted a bill to Horizon on behalf of D.A. 

detailing CPT[5] codes valued at $157,512.00. The 

[ninety percent] Fair Health value for those services for 

geozip 085 is $102,494.22. Horizon only paid 

$45,251.00, therefore leaving a balance of $57,561.22. 

B. [PNS] submitted a bill on behalf of K.C. detailing 

CPT codes valued at $351,384.00. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$219,317.93. Horizon only paid $116,935.75, therefore 

leaving a balance of $67,099.50. 

3

 FAIR Health, Benchmarks That Mirror the Market, 

https://www.fairhealth.org/methodologies (last visited Jan. 9, 2024). 

4

 FAIR Health, Frequently Asked Questions, https://www.feeestimator.org/faq 

(last visited Jan. 9, 2024). 

5

 The American Medical Association (AMA) promulgates CPT codes for every 

procedure reimbursable by medical insurance providers. See CPT Codes, Then 

and Now, American Medical Association (Aug. 4, 2015), https://www.amaassn.org/practice-management/cpt/cpt-codes-then-and-now.
5 A-0486-22

C. [PNS] submitted a bill on behalf of J.C. detailing 

CPT codes valued at $115,161.00. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$79,238.19. Horizon only paid $4,948.87, therefore

leaving a balance of $16,736.10. 

D. [PNS] submitted a bill on behalf of D.C. detailing 

CPT codes valued at $151,749.00. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$104,931.11. Payment should be [twenty percent] of

the billed charges according to the [ninety percent] Fair 

Health value, which totals $30,349.80. Horizon only 

paid $7,871.95, therefore leaving a balance of 

$22,477.85. 

E. [PNS] submitted a bill on behalf of M.G. detailing 

$220,978.00 worth of services. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$145,106.97. Horizon only paid $68,208.00, therefore 

leaving a balance of $96,537.00. 

F. [PNS] submitted a bill on behalf of D.K. detailing 

CPT codes valued at $221,805.00. The [seventy 

percent] Fair Health value for those services for geozip 

085 totaled $100,669.00. Horizon only paid 

$74,931.20, therefore leaving a balance of $25,737.80. 

G. [PNS] submitted a bill on behalf of T.M. detailing 

CPT codes valued at $82,093.00. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$48,587.70. Horizon only paid $23,198.00, therefore 

leaving a balance of $25,389.70. 

H. [PNS] submitted a bill on behalf of P.M. detailing 

CPT codes valued at $151,749.00. The [ninety percent] 

Fair Health value for those services for geozip 085 is 

$112,176.28. Horizon only paid $62,083.00, therefore 

leaving a balance of $50,093.28. 
6 A-0486-22

I. [PNS] submitted a bill on behalf of B.M. detailing 

CPT codes valued at $257,145.00. The [ninety percent] 

Fair Health value for those services for geozip 085

totaled $119,290.59. Horizon only paid $6,714.94, 

therefore leaving a balance of $13,157.54. 

J. [PNS] submitted a bill on behalf of D.R. detailing 

CPT codes valued at $168,001.00. The [ninety percent] 

Fair Health value for those services for geozip 085 with 

the appropriate [twenty percent] balance is $76,790.40. 

Horizon only paid $37,413.75, therefore leaving a 

balance of $39,376.65. 

In total, PNS claimed Horizon underpaid $414,166.14, despite that during the 

verification calls Horizon represented it would pay: ninety percent of Fair 

Health value for D.A., K.C., J.C., D.C., M.G., T.M., P.M., B.M., and D.R.; and 

seventy percent of Fair Health value for D.K. 

Eight of the patients were covered under the State Health Benefits Plan 

(SHBP), which is governed by the State Health Benefits Commission. The 

SHBP Member Handbook qualifies what it will pay by repeatedly stating it 

"covers only reasonable and customary allowances . . . determined by the FAIR 

Health benchmark charge data or a similar nationally recognized database." The 

SHBP patients were K.C., J.C., D.C., M.G., T.M., P.M., B.M., and D.R. D.K. 

and D.A. were covered under Horizon plans governed by the Employee 

Retirement Income Security Act (ERISA). 
7 A-0486-22

At summary judgment, Horizon cited the SHBP and noted that aside from 

using the FAIR Health or PHCS databases to calculate the payment to an outof-network provider, reimbursement was subject to "terms, conditions, and 

limitations of the health benefits plan and Horizon's administration of the same." 

Horizon noted the ERISA-governed health benefits plans gave Horizon 

"considerable discretion" to decide what was covered and what to pay PNS for 

treating D.K. or D.A. Horizon's discretion included the ability to decide whether 

a service was "'incidental' to another service or contrary to the 'framework of 

generally accepted methods of medical management currently used in the United 

States.'" 

 FAIR Health releases updated data every May and November. Horizon 

updates its system with the May data in July and the November data in January. 

On November 18, 2016, the Horizon customer service representative told 

PNS that D.K.'s out-of-network benefits would be reimbursed at the FAIR 

Health seventieth percentile. PNS never asked, and Horizon never specified, 

whether it would use the May 2016 or November 2016 FAIR Health data to 

calculate reimbursement. Furthermore, as noted in the parties' joint statement 

of undisputed facts, PNS had not seen D.K. for an initial consultation when it 

made the insurance verification call with Horizon. On January 4, 2017, D.K. 
8 A-0486-22

had her surgery and PNS submitted its claim to Horizon two days later. Horizon 

paid PNS at the seventieth percentile of the FAIR Health database, using the 

May 2016 FAIR Health data because the November 2016 data was not made 

effective in Horizon's system until January 29, 2017.6 PNS disputed Horizon's 

use of the November 2016 FAIR Health data. However, a PNS employee 

testified at deposition that Horizon never told PNS it was going to use the most 

recent FAIR Health data, and PNS never told Horizon it expected reimbursement 

would be based on the latest FAIR Health data. 

On February 13, 2015, PNS made the insurance verification call to 

Horizon regarding D.A. Like D.K., PNS does not dispute it did not know what 

services it would provide or how much it would charge Horizon, because D.A.'s 

initial consultation had not yet occurred. Horizon told PNS D.A.'s out-ofnetwork benefits would be reimbursed at the ninetieth percentile of the FAIR 

Health data. Following the call, PNS saw D.A. and then sought prior 

authorization from Horizon for the services PNS deemed necessary, which 

Horizon granted on February 27, 2015. 

6

 Horizon further reduced the sum it paid because one procedure submitted by 

PNS was considered incidental to another procedure. PNS does not dispute the 

secondary deduction. 
9 A-0486-22

D.A.'s plan defined an allowed charge as the "standard approved by 

[Horizon's] Board." As a result, Horizon reimbursed PNS at the eightieth 

percentile of the PHCS profile. The parties do not dispute this did not match 

what the Horizon representative told PNS during the insurance verification call. 

Also, PNS submitted a claim form noting D.A.'s procedure took place in 

Plainsboro, but the billing address was noted as Hamilton. FAIR Health uses 

the geozip for the location of the procedure. However, Horizon applied the 

geozip for the billing address. PNS claimed it expected Horizon to reimburse 

according to the procedure geozip. 

 In 2019, PNS sued Horizon alleging five common law causes of action, 

including, as relevant here, promissory estoppel and negligent 

misrepresentation. Horizon moved to dismiss the complaint as pertained to the 

eight SHBP patients on grounds the Law Division lacked subject matter 

jurisdiction because the Commission had final authority over payment of 

benefits and resolutions of disputes. The court entered the August 16, 2019 

order, directing PNS to present its claims to the Commission and granting 

Horizon's motion. 

 PNS moved for leave to file an amended complaint, alleging it had no 

standing to bring claims before the Commission because it was not a legal 
10 A-0486-22

representative of the SHBP patients. The court entered the November 15, 2019 

order denying PNS's motion, and held the SHBP patients were indispensable 

parties to PNS's common law claims and therefore a motion to amend would be 

futile. PNS's subsequent motion for reconsideration was denied. 

 In 2021, PNS moved for summary judgment on the remaining claims 

relating to D.A. and D.K. Horizon cross-moved for summary judgment, arguing 

PNS's claims were preempted by ERISA. The court entered the September 2, 

2022 orders, denying PNS's motion and granting Horizon's cross-motion 

dismissing each count of the complaint. The court issued a separate opinion, 

finding PNS's claims were "expressly preempted by Section 514 [of ERISA] 

because they impermissibly 'relate to' and make 'reference to' D.K.'s and D.A.'s 

ERISA-governed health benefits plans." 

I.

 On appeal, PNS argues the August 16, 2019 order finding the court lacked 

subject matter jurisdiction was based on an erroneous interpretation of Beaver 

v. Magellan Health Services, Inc., 433 N.J. Super. 430 (App. Div. 2013). 

Likewise, the November 15, 2019 order denying PNS's motion to amend the 

complaint because it lacked standing before the Commission was erroneous. 
11 A-0486-22

PNS asserts the court's reliance on Beaver was misplaced because there 

the plaintiff had standing as a beneficiary to raise claims before the Commission, 

but then sued in the Law Division as a collateral challenge to a final agency 

decision "cloak[ed] . . . under the mantle of contract and tort." Id. at 441. The 

plaintiff in Beaver had already unsuccessfully appealed the agency decision and 

conceded the new case was brought to recover "unpaid benefits." Ibid. PNS 

argues, therefore, that Beaver is distinguishable. 

PNS asserts the court clearly had jurisdiction because a provider cannot 

appeal a claim to the Commission. It notes the assignment of benefits signed by 

patients does not cure the standing issue either. Further, its reimbursement 

claims did not require a determination by the Commission because the dispute 

with Horizon regarded the reimbursement methodology, which the court was 

capable of adjudicating. 

"Whether subject matter jurisdiction exists presents a purely legal 

issue . . . ." Santiago v. N.Y. & N.J. Port Auth., 429 N.J. Super. 150, 156 (App. 

Div. 2012) (internal citations omitted). Therefore, our review is de novo. Ibid. 

There is no dispute PNS lacked standing before the Commission because 

it was not a member of the health plans administered by the Commission. 

N.J.A.C. 17:9-1.3 allows any "member" to pursue complaints internally with the 
12 A-0486-22

plan, and if the matter is unresolved, the member "may request that the matter 

be considered by the Commission." A member is defined as any covered 

individual, whether a "subscriber or a dependent." N.J.A.C. 17:9-1.8. The 

Horizon Member Guidebook reiterates "[o]nly the member or the member's legal 

representative may appeal, in writing, to the [Commission]." 

The Commission was created by the New Jersey Health Benefits Program 

Act, which "establishes a plan for state funding and private administration of a 

health benefits program . . . ." Heaton v. State Health Benefits Comm'n, 264 

N.J. Super. 141, 151 (App. Div. 1993); see N.J.S.A. 52:14-17.24 to -45. "The 

[SHBP] is, in effect, the State of New Jersey acting as a self-insurer." Burley v. 

Prudential Ins. Co. of Am., 251 N.J. Super. 493, 495 (App. Div. 1991). 

"[T]he [Commission] alone has the authority and responsibility to make 

payments on claims and to limit or exclude benefits." Beaver, 433 N.J. Super. 

at 433 (citing N.J.S.A. 52:14-17.29(B)). The Act empowers the Commission to 

create "rules and regulations as may be deemed reasonable and necessary for 

[its] administration . . . ." N.J.S.A. 52:14-17.27(a). Pursuant to this authority 

the Commission adopted N.J.A.C. 17:9-1.3, which permits only members, not 

providers, to pursue appeals with the Commission. 
13 A-0486-22

Therefore, the trial court's jurisdictional ruling was correct. The central 

issue was the reimbursement methodology used to pay PNS. This necessitated 

an interpretation of the SHBP, which can only be performed by the Commission. 

The Commission alone has the authority to adjudicate disputes related to the 

SHBP, N.J.S.A. 52:14-17.27, and through N.J.A.C. 17:9-1.3, created a 

regulatory scheme whereby only members have standing to pursue 

reimbursement claims. As a result, the court also properly denied PNS's motion 

to amend the complaint because it would not resolve PNS's lack of standing. 

II. 

 PNS argues its claims regarding D.K.'s and D.A.'s ERISA-governed plans 

were not preempted because the Third Circuit has held state common law claims 

are not claims for benefits due under an ERISA plan in Plastic Surgery Center, 

P.A. v. Aetna Life Insurance, 967 F.3d 218, 229 (3d Cir. 2020)). PNS likens its 

case to Plastic Surgery and argues its promissory estoppel claim arose when 

Horizon made representations to PNS regarding payment, which the court could 

adjudicate without interpreting the ERISA plans. 

In Plastic Surgery, the Third Circuit ruled that a promissory estoppel claim 

by an out-of-network provider for payment under an Aetna health plan was not 

preempted by ERISA. Id. at 230. The court held the preemption of a common 
14 A-0486-22

law claim by ERISA depends on whether it seeks to "enforce obligations 

independent of the plans" or if a determination of liability requires construction 

of the terms of the plans. Ibid. 

PNS asserts the trial court applied too stringent of a standard because, in 

effect, its ruling was that any reference to ERISA triggers preemption. PNS 

argues its claims were not tethered to the plan, because the dispute regarded its 

request for payment under "an appropriate percentile of FAIR Health" and its 

reliance on Horizon's representations of what it would pay for D.K.'s and D.A.'s 

treatment. In other words, like Plastic Surgery, preemption played no role 

because: the dispute was not one that ERISA intended to govern; its claims did 

not interfere with the administration of the ERISA plan; and preemption would 

undermine ERISA's purpose by permitting insurers to induce out-of-network 

providers to provide services with knowledge ERISA's preemption would bar 

payment to the providers. 

"A trial court's interpretation of the law and the legal consequences that 

flow from established facts are not entitled to any special deference." 

Manalapan Realty, L.P. v. Twp. of Manalapan, 140 N.J. 366, 378 (1995). 

"Whether a state law claim is preempted by ERISA is a question of law which 

is reviewed de novo." Feit v. Horizon Blue Cross & Blue Shield of N.J., 385 
15 A-0486-22

N.J. Super. 470, 482 (App. Div. 2006) (quoting Finderne Mgmt. Co. v. Barrett, 

355 N.J. Super. 170, 185 (App. Div. 2002)). 

 We are unpersuaded by PNS's arguments. Section 514(a) of ERISA 

preempts state law claims that "relate to" an ERISA plan. 29 U.S.C. § 1144(a). 

As the trial court noted, the scope of State laws preempted by this provision is 

expansive, encompassing "all laws, decisions, rules, regulations, or other State 

action having the effect of law, of any state[.]" Menkes v. Prudential Ins. Co. 

of Am., 762 F.3d 285, 294 (3d Cir. 2014). A State law "relates to" an ERISA 

plan if it has either a "reference to" or a "connection with" that plan. Shaw v. 

Delta Air Lines, Inc., 463 U.S. 85, 97 (1983). 

Plastic Surgery is inapposite. There, the out-of-network provider was not 

entitled to reimbursement and entered a separate agreement with the insurer, to 

cover a specific procedure for the patient "along with related medical services" 

and pay "a reasonable amount for those services according to the terms of the 

[ERISA p]lan." 967 F.3d at 224, 232. The insurer "agreed to approve and pay 

for" the surgery at the "highest in[-]network level." Id. at 224 (alteration in 

original). The Third Circuit held: 

Whether the [provider] seeks to enforce 

obligations independent of the plan turns on whether 

the parties agreed (i) that [the insurer] would provide 

payment for all services necessary to perform the 
16 A-0486-22

respective surgeries, leaving only the amount of 

payment pegged to the terms of the plan; or (ii) that the 

scope of coverage, as well as payment, would be 

limited to the terms of the plans—leaving open the 

possibility that some services would not be 

compensated at all. 

[Id. at 231 (internal citation omitted).] 

 Here, the record reveals no express or implied agreement, let alone a 

promise that cross-referenced D.A. and D.K.'s ERISA plans as the parties had 

in Plastic Surgery. Moreover, reimbursement remained contingent upon the 

services D.A. and D.K.'s plans deemed necessary or incidental. In D.K.'s case, 

there was no representation Horizon would apply the November 2016 FAIR 

Health values, and Horizon was not mandated by law to apply the updated FAIR 

Health figures. In D.A.'s case, Horizon was not required to reimburse using the 

address where PNS rendered services. Although Horizon's application of the 

PHCS methodology for reimbursement in D.A.'s case contradicted what its 

representative told PNS during the insurance verification call, the call was 

preceded by a disclaimer and the prior authorization did not pertain to the 

payment or result in a payment agreement. 

III.

 PNS challenges the summary judgment ruling dismissing its promissory 

estoppel and negligent misrepresentation claims. It contends Horizon made a 
17 A-0486-22

promise, which induced PNS to render services to the patients. Further, the 

court erred by finding there was no reliance because the disclaimer abjured a 

guaranty of payment, which had nothing to do with Horizon's duty to provide 

accurate information to out-of-network providers like PNS. 

Summary judgment is appropriate "if the pleadings, depositions, answers 

to interrogatories and admissions on file, together with the affidavits, if any, 

show that there is no genuine issue as to any material fact challenged and that 

the moving party is entitled to a judgment or order as a matter of law." R. 4:46-

2(c). The court considers "whether the competent evidential materials 

presented, when viewed in the light most favorable to the non-moving party, are 

sufficient to permit a rational factfinder to resolve the alleged disputed issue in 

favor of the non-moving party." Brill v. Guardian Life Ins. Co., 142 N.J. 520, 

540 (1995). "[W]hen the evidence 'is so one-sided that one party must prevail 

as a matter of law,' . . . the trial court should not hesitate to grant summary 

judgment." Ibid. (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252 

(1986)). "[W]e review [a] trial court's grant of summary judgment de novo 

under the same standard as the trial court." Templo Fuente De Vida Corp. v. 

Nat'l Union Fire Ins. Co., 224 N.J. 189, 199 (2016). 
18 A-0486-22

 Promissory estoppel requires: "(1) a clear and definite promise; (2) made 

with the expectation that the promisee will rely on it; (3) reasonable reliance; 

and (4) definite and substantial detriment." Goldfarb v. Solimine, 245 N.J. 326, 

339-40 (2021) (quoting Toll v. Bd. of Chosen Freeholders, 194 N.J. 223, 253 

(2008)). A party asserting a negligent misrepresentation claim must show the 

defendant had a duty of care. Zielinski v. Pro. Appraisal Assocs., 326 N.J. 

Super. 219, 224 (App. Div. 1999). Whether a duty exists is a matter of law 

determined by the court after "balancing several factors" including "the 

relationship of the parties, the nature of the attendant risk, the opportunity and 

ability to exercise care, and the public interest in the proposed solution." Carter 

Lincoln-Mercury, Inc., Leasing Div. v. EMAR Grp., Inc., 135 N.J. 182, 194 

(1994) (quoting Hopkins v. Fox & Lazo Realtors, 132 N.J. 426, 439 (1993)). 

 The trial court correctly concluded PNS's promissory estoppel claim failed 

because as we noted in section II, Horizon did not promise PNS anything. The 

lack of a promise was confirmed by Horizon's disclaimer. Moreover, PNS could 

not have reasonably relied on Horizon's representations as it had not seen the 

patients, let alone rendered services to them at the time of the authorization call 

with Horizon. 
19 A-0486-22

The negligent misrepresentation claim could not survive summary 

judgment because Horizon's duty was to its insured beneficiaries, not PNS. 

Horizon had no contract with PNS. We recognize Plastic Surgery found the 

opposite, but there the insurer and the out-of-network provider had a contract. 

Therefore, the court found leaving out-of-network providers with no means of 

enforcing their contract 

would in effect allow insurers to illegitimately 

supplement their provider network by making promises 

of payment to induce the provision of services, safe in 

the knowledge that those out of network would have no 

recourse for breach of those promises. The 

consequence . . . would be for providers to begin to 

require up-front payments from patients or to "deny

care or raise fees to protect themselves against the risk 

of noncoverage." 

[Plastic Surgery, 967 F.3d at 239 (quoting Lordmann

Enters. v. Equicor, Inc., 32 F.3d 1529, 1533 (11th Cir. 

1994).] 

Setting aside that PNS and Horizon did not have a contract, we are not 

convinced the concerns raised in Plastic Surgery exist here. We are not 

persuaded it would serve the public interest to bind Horizon based upon an 

authorization call that was subject to a disclaimer. To find a duty under these 

circumstances would harm insureds, because Horizon would be hesitant to field 

calls from out-of-network providers, who in turn would decline to provide 
20 A-0486-22

services to the insureds because they could not obtain authorization from the 

insurer. 

 Finally, Horizon did not misrepresent a fact that PNS justifiably relied 

upon. Even in the case of mistaken representation regarding the reimbursement 

methodology in D.A.'s case, there was no reasonable reliance because PNS did 

not know D.A.'s diagnosis or the CPT codes it intended to bill. Therefore, the 

payment PNS would receive was not yet known. 

For these reasons, summary judgment in Horizon's favor was properly 

granted. To the extent we have not addressed an argument raised on appeal, it 

is because it lacks sufficient merit to warrant discussion in a written opinion. R.

2:11-3(e)(1)(E). 

Affirmed.