reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 1 - COMMERCIAL AUTOMOBILE INSURANCE PLAN › Section 11:3-1.12 - CAIP participation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer admitted to transact and transacting motor vehicle insurance in the State of New Jersey shall participate in CAIP to the extent required by this subchapter and the AIP plan of operation. At the end of each fiscal period, CAIP's operating profit or loss shall be determined separately for each policy year. Profit shall be credited or distributed to each participant and loss shall be charged against each participant as set forth in the AIP plan of operation.
(b) All data necessary to comply with the foregoing participation procedures shall be reported to the CAIP's central statistical agent in the manner described in the approved statistical plan.
(c) Groups of participants under the same ownership and management shall be treated as a single participant. Groups of participants under either the same ownership or management, but not both, may elect to be treated either separately or as a single company.
(d) In the event a participant discontinues writing motor vehicle liability or physical damage insurance in this State and retains its certificate of authority to write such business, it shall continue to pay assessments, provided, however, that if the automobile liability or physical damage business of a participant discontinuing the writing of automobile liability or physical damage insurance in this State has been purchased by, transferred to, or reinsured by another company, the latter shall receive the assessments of the former.
(e) In the event a participant is merged with another company or there is a consolidation of companies, the continuing company shall receive the assessments of the company merged or consolidated, provided, however, the continuing company may be relieved from such obligations if another company has agreed, in a manner satisfactory to the Governing Committee, to assume such obligations.
(f) Participation shall be suspended upon order of the Commissioner of Banking and Insurance if he or she finds that such action is required by the financial condition of that participant.
(g) All participants in CAIP shall participate in the business written by the CAIP pursuant to an approved AIP plan of operation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 1 - COMMERCIAL AUTOMOBILE INSURANCE PLAN › Section 11:3-1.13 - Rates and policy forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Governing Committee shall file for prior approval by the Commissioner, all rates, rules surcharges, minimum premiums, classifications, and policy forms which shall be used by insurers writing risks through the AIP. Proceedings to review rate filings shall be conducted pursuant to
N.J.S.A. 17:29A-1
et seq. All rates shall reflect the experience of the risks insured by the AIP and shall not be excessive, inadequate, or unfairly discriminatory. Every rate filing shall include an analysis of the adequacy of the rating plans. Premiums for risks shall be subject to the rating plan established in the plan of operation.
(b) Any risk with five or more vehicles not including trailers and semi-trailers shall be considered as a fleet. The AIP shall file base rates for fleets with the Commissioner for his or her prior approval which are different than the rates for non-fleet risks if the AIP determines that the loss expectancy of fleet risks insured by the AIP is different than the loss expectancy of non-fleet risks insured by the AIP.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 1 - COMMERCIAL AUTOMOBILE INSURANCE PLAN › Section 11:3-1.14 - Installment payment option

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The PAIP shall provide for an installment premium payment option in accordance with procedures established by the Governing Committee in the AIP plan of operation. With respect to the installment premium payment option, the AIP plan of operation shall specify:
1. The minimum initial deposit required, which shall be no more than 30 percent of the estimated total premium;
2. The schedule for the payment of premiums on an installment basis which shall provide for installment payments over a period of not less than nine months;
3. Installment charges;
4. The minimum "per installment" amounts; and
5. Any other procedures deemed necessary by the Governing Committee.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 1 - COMMERCIAL AUTOMOBILE INSURANCE PLAN › Section 11:3-1.15 - Right to petition for appeal to the Commissioner

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An applicant, insured, producer, LAD carrier, CAIP servicing carrier, person applying to act as a LAD carrier or CAIP servicing carrier, or insurer may petition for appeal to the Commissioner from an adverse decision of the Governing Committee by filing a request in writing within 20 days of the date of receipt of the written decision of the Governing Committee.
1. The written request to appeal shall set forth the facts upon which it is based and include a copy of the written decision of the Governing Committee.
2. The Commissioner shall notify the petitioner and the Governing Committee within 30 days whether the request to appeal shall be granted.
3. Notice from the Commissioner that an appeal has been granted shall also provide a statement about whether the action of the Governing Committee has been stayed pending the disposition of the appeal.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to assist certain low income individuals in this State and encourage their greater compliance in satisfying the mandatory private passenger automobile insurance requirements imposed by 39:6A-3.2.
(b) This subchapter shall apply to all insurers transacting private passenger automobile insurance in this State, the PAIP and to all insurance producers licensed in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Department" means the New Jersey Department of Banking and Insurance.
"Emergency care" means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include, but not be limited to, immediate pre-hospitalization care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. It shall also include all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement after the patient is discharged from acute care.
"Emergency personal injury protection coverage" means the payment of benefits without regard to negligence, liability or fault of any kind, only to the named insured and dependant members of his or her family, as defined by the Federal Medicaid program, residing in his or her household, who sustain bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile, and to other persons sustaining bodily injury while occupying, entering into, alighting from or using the automobile of the named insured, with the permission of the named insured.
"Insurer" means an entity authorized or admitted to transact insurance in this State pursuant to 17:17-1 et seq. or 17:32-1 et seq., as applicable.
"Insurance producer" means a person required to be licensed under the laws of this State to sell, solicit or negotiate insurance.
"LAD carrier" means a limited assignment distribution carrier that is a participating insurer and that agrees to accept assignments of another insurer pursuant to this subchapter and procedures set forth in the plan of operation.
"PAIP" means the New Jersey Personal Automobile Insurance Plan established pursuant to 17:29D-1 and N.J.A.C. 11:3-2.
"UCJF" means the Unsatisfied Claim and Judgment Fund, established pursuant to 39:6-61 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.3 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The special automobile insurance policy shall be administered by the PAIP in accordance with a Special Policy plan of operation prepared by PAIP and approved by the Commissioner. The plan of operation shall include:
1. The procedure for the writing of Special Insurance Policies by:
i. Assignment of special automobile insurance policies to the member insurers of the PAIP pursuant to the apportionment methodology of the PAIP Plan of Operation; or
ii. The sharing of the premium, losses and expenses of the special automobile policies among the member insurers of the PAIP;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.4 - Eligibility for special automobile insurance policy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The special automobile insurance policy shall only be available to individuals who are eligible for and enrolled in the Federal Medicaid program pursuant to N.J.S.A. 30:4D-3i(1) through (14).
(b) The PAIP special automobile insurance policy plan of operation shall provide procedures for verification of the Medicaid eligibility of applicants.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.5 - Coverages

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following coverages shall be included in all special automobile insurance policies:
1. Emergency personal injury protection coverage for emergency care not to exceed $ 250,000 per person per accident; and
2. A death benefit in the amount of $ 10,000.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 2A - SPECIAL AUTOMOBILE INSURANCE POLICY › Section 11:3-2A.6 - Election of special automobile insurance policy

Current through Register Vol. 56, No. 14, July 15, 2024
No insurer shall issue a special automobile insurance policy unless the named insured has signed a document entitled Special Policy Coverage Selection Form approved by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter provides rules to be utilized by insurers in developing the policy forms and rates for basic automobile insurance policies to be filed with and approved by the Department in accordance with the provisions of 39:6A-3.1.
(b) This subchapter shall apply to all insurers writing private passenger automobile insurance on personal lines policy forms, including the New Jersey Personal Automobile Insurance Plan established by N.J.A.C. 11:3-2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Basic automobile insurance policy" or "basic policy" means that automobile insurance policy offered pursuant to 39:6A-3.1 and this subchapter.
"Basic policy servicing carrier" means a limited assignment distribution carrier that is a participating insurer that agrees to accept assignments of basic policies pursuant to this subchapter and the procedures set forth in the PAIP plan of operation.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Department" means the Department of Banking and Insurance.
"Insurer" means any person or persons, corporation, association, partnership, company, reciprocal exchange, or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a group of affiliated companies that transacts business in accordance with a common rating system.
"Medically necessary" is as defined in 11:3-4.2.
"PAIP" means the New Jersey Personal Automobile Insurance Plan established pursuant to 17:29D-1 and N.J.A.C. 11:3-2.
"Personal injury protection" or "PIP" means the benefits and coverages set forth at 39:6A-4 and 39:6A-3.1 and N.J.A.C. 11:3-4.
"Significant disfigurement" means the result and/or manifestation of a serious traumatic injury that is observable as a permanent and substantial defect in the appearance and functional ability of the person injured. "Significant disfigurement" is a serious outward change that substantially detracts from the appearance and functional ability of the person injured.
"Standard automobile insurance policy" or "standard policy" means that policy form filed by private passenger automobile insurers and approved by the Commissioner that contains the coverages and options pursuant to 39:6A-4.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.3 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All insurers writing private passenger automobile insurance and the Personal Automobile Insurance Plan shall file for approval with the Department their rates, rules and policy forms for a basic automobile insurance policy to be issued in accordance with 39:6A-3.1 and this subchapter.
(b) An insurer shall make available the basic policy at either a single tier rate or at multiple tier rates, consistent with its tier rating system filed and approved pursuant to N.J.A.C. 11:3-19A. If more than one basic policy rate is offered, each shall be identified as part of a standard, non-standard or preferred tier.
(c) If a named insured has elected basic automobile insurance coverage and other immediate family members or resident relatives of the named insured have higher policy limits under a standard policy, the provisions of 39:6A-4.2 shall apply and the named insured shall only be entitled to the coverages provided under his or her basic policy.
(d) Basic policies shall provide the tort option provided under N.J.S.A. 39:6A-8a.
(e) Initial rates by coverage for basic policies filed in accordance with this subchapter shall demonstrate consistency with the rates in the insurer's standard policy, adjusted for reduced coverage limits.
(f) Insurers shall file for approval an initial basic policy rating system by January 20, 1999.
(g) An insurer may write basic policies through a basic policy servicing carrier.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.4 - Coverages; mandatory and optional

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following coverages shall be included in all basic policies:
1. Personal injury protection medical expense benefits coverage in an amount not to exceed $ 15,000 per person, per accident; except that all medically necessary treatment of permanent or significant brain injury, spinal cord injury or disfigurement or medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable, no longer requiring critical care and can be safely discharged or transferred to another facility in the judgment of the attending physician shall be covered in an amount not to exceed $ 250,000, including the $ 15,000 above. The medical expense benefits provided herein shall be in accordance with N.J.A.C. 11:3-4; and
2. Liability insurance coverage insuring against loss resulting from liability imposed by law for property damage sustained by any person arising out of the ownership, maintenance, operation or use of an automobile in an amount or limit of $ 5,000, exclusive of interest and costs, for damage to property in any one accident.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.5 - Election of basic automobile insurance policy coverage and reporting

Current through Register Vol. 56, No. 14, July 15, 2024
No insurer shall issue a basic automobile insurance policy unless the named insured has signed a written document entitled "basic automobile insurance policy coverage selection form" set forth in 11:3-15.7.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3 - BASIC AUTOMOBILE INSURANCE POLICY › Section 11:3-3.6 - Filing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Insurers initially filing basic policy rating systems shall include the following:
1. A complete set of policy forms and endorsements that provide the mandatory and optional coverages as set forth in this subchapter;
2. Rates and rules as necessary;
3. An actuarial memorandum that supports the rate differentials from the insurer's standard policy rates;
4. The declaration page;
5. The rating information form; and
6. The personal lines filing forms as set forth at N.J.A.C. 11:3-16.3(d).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3A - REPORTING REQUIREMENTS AND FILING DEADLINES › Section 11:3-3A.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter consolidates reporting obligations from various rules into one subchapter to result in one efficient, time-saving procedure.
(b) This subchapter applies to all insurers that write private passenger automobile insurance in this State as defined in 11:3-3A.2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3A - REPORTING REQUIREMENTS AND FILING DEADLINES › Section 11:3-3A.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Insurer" means any person authorized to write automobile insurance in New Jersey, including any residual market mechanism, and includes all affiliated companies with a group.
"Private passenger automobile" means a vehicle that meets the definition of "automobile" set forth at 39:6A-2.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3A - REPORTING REQUIREMENTS AND FILING DEADLINES › Section 11:3-3A.3 - Report requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All private passenger automobile insurers are required to file the following reports on a semi-annual basis, reflecting data from the last 12 months, and showing the residual market separately from the voluntary data, for the evaluation dates of December 31 and June 30 of each year:
1. The Private Passenger Semi-Annual Reports;
2. The Limits of Liability Report;
3. The Coverage Option Survey--Personal Injury Protection ("PIP") Deductibles, Threshold Options; and
4. PIP Medical Expense Limits Report.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 3A - REPORTING REQUIREMENTS AND FILING DEADLINES › Section 11:3-3A.4 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the provisions of this subchapter may result in the imposition of penalties pursuant to 17:33-2 and as otherwise authorized by law.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter implements the provisions of 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injury protection medical expense benefits and emergency personal injury protection coverage for which reimbursement of eligible charges will be made by automobile insurers under basic, standard and special automobile insurance policies and by motor bus insurers under medical expense benefits coverage.
(b) This subchapter applies to all insurers that issue policies of automobile insurance containing PIP coverage, emergency personal injury protection coverage and policies of motor bus insurance containing medical expense benefits coverage.
(c) This subchapter shall apply to those policies that are issued or renewed on or after March 22, 1999.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.3 - Personal injury protection benefits applicable to basic and standard policies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Personal injury protection coverage shall provide reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident up to the limits set forth in the policy and in accordance with this subchapter.
(b) Personal injury protection coverage shall only provide reimbursement for clinically supported necessary non-medical expenses that are prescribed by a treating medical provider for a permanent or significant brain, spinal cord or disfiguring injuries.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.4 - Deductibles and co-pays

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each insurer shall offer a standard $ 250.00 deductible and 20 percent copayment on medical expense benefits payable between $ 250.00 and $ 5,000.
(b) Each insurer shall also offer, at appropriately reduced premiums, the option to select medical expense benefit deductibles of $ 500.00, $ 1,000, $ 2,000 and $ 2,500 in accordance with the following provisions:
1. Any medical expense deductible elected by the named insured shall apply only to the named insured and any resident relative in the named insured's household, who is not a named insured under another automobile policy and not to any other person eligible for personal injury protection benefits required to be provided in accordance with 39:6A-3.1 and 39:6A-4;
2. Premium credits calculated and represented as a percentage of the applicable premium shall be provided for each deductible. The premium percentage shall be uniform by filer on a statewide basis; and
3. The deductible option elected by the named insured shall continue in force as to subsequent renewal or replacement policies until the insurer or its authorized representative receives a properly executed coverage selection form to eliminate or change the deductible.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.5 - Diagnostic tests

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The personal injury protection medical expense benefits coverage shall not provide reimbursement for the following diagnostic tests, which have been determined to yield no data of any significant value in the development, evaluation and implementation of an appropriate plan of treatment for injuries sustained in motor vehicle accidents:
1.
(Reserved)
2. Spinal diagnostic ultrasound;
3. Iridology;
4. Reflexology;
5. Surrogate arm mentoring;
6. Surface electromyography (surface EMG);
7.
(Reserved); and
8. Mandibular tracking and stimulation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.6 - Medical protocols

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 39:6A-3.1 and 39:6A-4, the Commissioner designates the care paths, set forth in the subchapter Appendix incorporated herein by reference, as the standard course of medically necessary treatment, including diagnostic tests, for the identified injuries.
(b) Where the care path indicates a decision point either by a hexagon in the care path itself or by reference in the text to a second opinion, referral for a second independent consultative medical opinion, development of a treatment plan or mandatory case management, the policy shall provide for a decision point review in accordance with 11:3-4.7.
(c) Treatments that vary from the care paths shall be reimbursable only when warranted by reason of medical necessity.
(d) The care paths do not apply to treatment administered during emergency care.
LAW REVIEW AND JOURNAL COMMENTARIES:
What's Next for No Fault? Gerald H. Baker, 159 N.J.L.J. 267 (2000).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.7 - Decision point review plans

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No insurer shall impose the co-payments permitted in 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan.
1. Initial decision point review plan filings and amendments to approved plans shall be submitted to the Department through the use of the NAIC electronic filing system SERFF (System for Electronic Rate and Form Filing).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.7A - PIP vendor registration requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section.
(b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file for registration by February 3, 2013.
(c) Application for registration shall be made on a form prescribed by the Commissioner, which can be found on the Department's website at
http://www.state.nj.us/dobi/pipinfo/aicrapg.htm
.
(d) The application shall be accompanied by the applicant's business plan, which shall include the following information:
1. A statement generally describing the applicant, its facilities, personnel, and the services to be offered by the PIP vendor;
2. The name of its medical director(s) licensed to practice as physician(s) in New Jersey and a detailed explanation about how the medical director(s) provide(s) oversight of determinations of medical necessity;
3. The name and contact information of a person at the vendor who is designated to receive and handle complaints and inquiries from the Department;
4. Information on activities undertaken or to be undertaken in New Jersey by the company;
5. A demonstration of the applicant's capability to provide a sufficient number of experienced and qualified personnel in the areas of PIP utilization management, and information on staffing levels, including, but not limited to, training, hiring requirements, experience of staff in general and with PIP utilization management in particular;
6. A statement about whether the applicant is licensed or certified as an entity that has networks as that term is defined in 11:3-4.8(a)  or accredited by nationally recognized accrediting agencies such as URAC (
http://www.urac.org/
) in Health Utilization Management; and
7. A copy of the applicant's certificate of incorporation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.7B - Requirements for insurer internal appeals procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The internal appeal procedure in an insurer's Decision Point Review Plan (DPR Plan) shall meet the requirements in this section.
(b) Insurers shall only require a one-level appeal procedure for each appealed issue before making a request for alternate dispute resolution in accordance with N.J.A.C. 11:3-5. That is, each issue shall only be required to receive one internal appeal review by the insurer prior to making a request for alternate dispute resolution. An appeal of the denial of a medical procedure, treatment, diagnostic test, other service, and/or durable medical equipment on the grounds of medical necessity is a different issue than an appeal of what the insurer should reimburse the provider for that same service.
(c) All appeals shall be initiated using the forms established by the Department by Order in accordance with 11:3-4.7(d)  and posted on the Department's website.
(d) The appeal forms and any supporting documentation shall be submitted by the provider to the address and/or fax number designated for appeals in the insurer's DPR Plan. Pursuant to N.J.A.C. 11:1-47, insurers may permit electronic filing of appeals by providing the process for electronic filing in its DPR Plan.
(e) There shall be two types of internal appeals:
1. Pre-service: Appeals of decision point review and/or precertification denials or modifications prior to the performance or issuance of the requested medical procedure, treatment, diagnostic test, other service and/or durable medical equipment (collectively known as "services"); and
2. Post-service: Appeals subsequent to the performance or issuance of the services.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.8 - Voluntary networks

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No insurer shall file a decision point review plan utilizing a voluntary network or networks unless the network is a health maintenance organization licensed pursuant to 26:2J-1 et seq.; or approved by the Department as part of a selective contracting arrangement with a health benefits plan pursuant to N.J.A.C. 11:4-37 and 11:24A-4.1 0; or approved as part of a workers' compensation managed care organization pursuant to N.J.A.C. 11:6; or is licensed or certified as an organized delivery system pursuant to N.J.A.C. 11:22-4 and 11:24B.
(b) Voluntary networks may be offered for the provision of the following types of non-emergency benefits only:
1. Magnetic Resonance Imagery;
2. Computer Assisted Tomography;
3. The electrodiagnostic tests listed in 11:3-4.5(b)1  through 3 except for needle EMGs, H-reflex and nerve conduction velocity (NCV) tests performed together by the treating physician;
4. Durable medical equipment with a cost or monthly rental in excess of $ 50.00;
5. Prescription drugs; or
6. Services, equipment or accommodations provided by an ambulatory surgery facility.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS › Section 11:3-4.9 - Assignment of benefits; public information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to 39:6A-4, an insured may only assign benefits and duties under the policy to a provider of service benefits. Insurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of personal injury protection benefits and duties under the policy, consistent with the efficient administration of the coverage and the prevention of fraud. Insurers may not prohibit the assignment of benefits to providers. Reasonable restrictions may include, but are not limited to:
1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer's decision point review plan for making decision point review and precertification requests;
2. A requirement that as a condition of assignment, the provider shall hold the insured harmless for penalty co-payments imposed by the insurer based on the provider's failure to follow the requirements of the insurer's decision point review plan; and/or
3. A requirement that as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by the personal injury protection coverage in policies of automobile insurance. This subchapter implements 39:6A-5.1 and 5.2, which provide that PIP disputes shall be resolved by binding alternate dispute resolution as provided in the policy form approved by the Commissioner. This subchapter also implements provisions of 2A:23A-1 et seq., as applicable to PIP dispute resolution.
(b) This subchapter shall apply to disputes arising under policies of private passenger automobile insurance, on either a personal lines or commercial lines policy form, that provide medical expense benefits and other benefits under personal injury protection coverage, as follows:
1. PIP benefits under a standard automobile insurance policy pursuant to 39:6A-4;
2. PIP benefits under a basic automobile insurance policy pursuant to 39:6A-3.1;
3. PIP benefits provided by the UCJF pursuant to 39:6-86.1; and
4. Additional PIP benefits provided pursuant to 39:6A-10.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.3 - Designation of the administrator

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall designate a dispute resolution organization as the administrator of the PIP alternate dispute resolution system by entering into a contract with a dispute resolution organization.
(b) The contract designating the administrator shall be for a term not to exceed five years, but may be extended according to its terms until a new administrator is designated and substituted. Nothing in this subsection shall prohibit an administrator from succeeding itself, if so designated in accordance with 39:6A-5.1 and this subchapter. The contract may provide for adjustments in the price paid for services performed over the life of the contract.
(c) The Commissioner shall request competitive proposals from among qualified dispute resolution organizations interested in serving as administrator.
(d) Dispute resolution organizations shall submit the following documents and information in connection with their proposal to serve as administrator:
1. A dispute resolution plan that describes how the organization shall meet the requirements of the Act and these rules, which shall include procedures and rules governing the dispute resolution process to ensure adherence to the standards of performance set forth in 39:6A-5.1 and 5.2 and this subchapter;
2. A description of the organization and biographical information about the key personnel that shall be responsible for executing the duties of the administrator;
3. A description of the management information systems that shall be utilized by the organization;
4. A draft budget for at least the first two years;
5. A cost proposal, which shall provide for the payment of the administrator's expenses, including the cost of dispute resolution professionals, from fees generated from the users of the system;
6. Such other information as may be provided by law, and that the Commissioner or the Treasurer may request in order to understand and evaluate the applicant's proposal.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.4 - Dispute resolution organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria:
1. The dispute resolution organization shall not be owned or controlled by an insurer or affiliate of an insurer;
2. The dispute resolution organization shall utilize full-time dispute resolution professionals that meet the standards set forth in 11:3-5.5. For the purpose of this paragraph, "full-time" shall be construed to include persons who work fewer than five days per week, but who do not engage in other, conflicting employment;
3. The dispute resolution organization shall utilize an advisory council composed of parties who are users of the dispute resolution mechanism in connection with the selection of dispute resolution professionals and the periodic review of the organization's rules and processes;
4. The dispute resolution organization shall utilize procedures to avoid conflicts of interests as prohibited at 11:3-5.1 2;
5. The dispute resolution organization shall arrange for proceedings in locations reasonably convenient to the parties;
6. The dispute resolution organization shall maintain published rules for the conduct of the proceedings, and shall make them available to the parties and the public upon request;
7. The dispute resolution organization shall perform its functions in a prompt and efficient manner, giving due regard to the nature of the proceeding and the need for special attention when required by the exigencies of a particular matter; and
8. The dispute resolution organization shall provide sufficient oversight and training of its dispute resolution professionals so as to promote fair, efficient and consistent determinations consistent with substantive law and with rules adopted by the Commissioner.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.5 - Dispute resolution professionals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A dispute resolution professional employed by the dispute resolution organization shall be either:
1. An attorney licensed to practice in New Jersey with at least 10 years of experience in cases involving personal injury or workers' compensation;
2. A former judge of the Superior Court or the Workers' Compensation Court, or a former Administrative Law Judge; or
3. Any other person, qualified by education and at least 10 years' experience, with sufficient understanding of automobile insurance claims and practices, contract law, and judicial or alternate dispute resolution practices and procedures.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.6 - Conduct of PIP dispute resolution proceedings

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A request for dispute resolution of a PIP dispute may be made by the injured party, the insured, a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or the insurer, in accordance with the terms of the policy as approved by the Commissioner. The request for dispute resolution may include a request for review by a medical review organization. The request shall be made to the administrator and copies sent to other parties.
1. Every insurer shall establish a single address where requests for dispute resolution shall be sent. Insurers shall notify the administrator of the address and any changes thereto. The administrator shall make the list of insurer addresses available to the user community on a web page and any other available means of communication.
2. Providers who are the assignee of benefits by the insured or have a power of attorney from the insured shall follow the insurer's internal appeal process mandated by N.J.A.C. 11:3-4.7B before making a request for dispute resolution in accordance with (a) above. The dispute resolution organization's plan shall include a procedure for how the provider shall demonstrate that this requirement has been satisfied.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.7 - Recordkeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The administrator shall maintain records of all determinations for a period of five years.
(b) The administrator shall file a copy of each determination, except consent determinations, with the Department in either hard copy or electronic form, as provided in the contract designating the administrator.
1. Any determination filed with the Department shall be indexed and coded so as to facilitate retrieval.
2. The name of any injured party, except when appearing in the caption of the matter or used as identification of the particular case, shall be redacted in the copy filed with the Department so as to protect the privacy of the injured person.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.8 - Medical review organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical review organizations shall be authorized to determine in connection with the PIP dispute resolution process set forth in this subchapter:
1. Whether the medical treatment or diagnostic test is medically necessary;
2. Whether the treatment is in accordance with medically recognized standard protocols including those protocols approved by the Commissioner and set forth in N.J.A.C. 11:3-4;
3. Whether the treatment is consistent with symptoms or diagnosis of the injury;
4. Whether the injury is causally related to the accident ;
5. Whether the treatment is of a palliative rather than a restorative nature; and
6. Whether medical procedures and tests that have been repeated are medically necessary.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.9 - Standards for medical review organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical review organizations shall be capable of performing medical reviews for all primary specialties and disciplines.
(b) Medical review organizations shall employ a medical director to actively participate in the review of cases to assure quality and consistency.
(c) Medical review organizations shall utilize health care providers in the same discipline as the treating provider to perform the reviews who meet the following standards:
1. Reviewing health care providers shall be active practitioners who obtain a minimum of one-half of their income from practice in their area of specialty;
2. Reviewing health care providers shall be licensed in New Jersey and board certified in their specialty;
3. Reviewing health care providers shall have at least two years' experience in medical review, or be certified as a medical review physician; and
4. Reviewing health care providers shall have completed an orientation with the MRO, including medical review instruction and report writing.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.10 - Medical review organization certification process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall certify a medical review organization to provide medical review services in connection with the resolutions of PIP disputes if the Commissioner determines that the MRO complies with the standards set forth in 11:3-5.9 to provide an impartial review of the medical necessity or appropriateness of treatments, health care services or items of durable medical equipment for which medical expense benefits may be provided under personal injury protection coverage.
(b) For the purpose of obtaining certification by the Commissioner to act as a medical review organization to perform medical review in connection with the resolution of PIP disputes, an MRO shall submit two copies of a written application that sets forth the information in (b) below to:
Medical Review Organization Certification
New Jersey Department of Banking and Insurance
PO Box 325
Trenton, NJ 08625-0325
(c) The MRO application shall include the following:
1. A list of the names, addresses and specialties of the individual health care providers that will provide the medical review services. If the MRO will be limited in its service area, the application shall provide a map of the service area, including the providers by specialty;
2. A copy of the MRO's certificate of incorporation and by-laws;
3. A diagram of the MRO's organizational structure;
4. The location of the MRO's place of business where it administers its services and maintains its records;
5. A listing and biography of the MRO's officers and directors, or the individuals in the organization responsible for administration of medical reviews, including the medical director;
6. A detailed description of the MRO's experience in the review of medical care;
7. A description of its procedures for review of medical treatments, diagnostic tests and items of durable medical equipment in conjunction with PIP medical expense benefits;
8. A current list identifying all property/casualty insurers, health insurers, health maintenance organizations and health care providers with whom the MRO maintains any health related business arrangement. The list shall include a brief description of the nature of the arrangement, so as to permit the administrator to avoid assignments that may create a conflict of interest;
9. The fee(s) for determinations by the MRO;
10. Such other information as the Commissioner may specifically request in connection with the certification of a particular applicant; and
11. A fee in the amount of $ 1,000 payable to the Department of Banking and Insurance.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.11 - Fees

Current through Register Vol. 56, No. 14, July 15, 2024
When a mental or physical examination is performed in connection with the medical review organization's services, the health care provider performing the examination shall be paid the fee provided for that service set forth on the Department's medical fee schedule, N.J.A.C. 11:3-29.