reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 24 - DEFENSIVE DRIVING RATE REDUCTIONS › Section 11:3-24.2 - 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:
"Automobile" means any private passenger automobile as defined in 39:6A-2 but does not include any automobile insured under a commercial insurance policy.
"Department" means the New Jersey Department of Banking and Insurance.
"Defensive driving course" means a course approved by MVC pursuant to N.J.S.A. 17:33B-45 and N.J.A.C. 13:21-24
"Motor vehicle points" means points accumulated as a result of a conviction of a motor vehicle violation(s) and other events that are set forth on an abstract of drivers license records that are available from the New Jersey Division of Motor Vehicles and are set forth in 13:19-10.1. Motor vehicle points are also listed in Schedule 2 of N.J.A.C. 11:3-34. Insurance eligibility points in Schedule 1 are not motor vehicle points.
"MVC" means the New Jersey Motor Vehicle Commission.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 24 - DEFENSIVE DRIVING RATE REDUCTIONS › Section 11:3-24.3 - Rate reduction filing requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer shall include in its rules for automobile insurance coverage rate reductions for the successful completion of a defensive driving course.
(b) The rate reduction for the completion of a defensive driving course should be a minimum of five percent and is to apply to the base premium before expense fees are added for bodily injury liability, property damage liability, personal injury protection and collision coverages. Insurers may use external sources and/or actuarial experience to justify a discount different than five percent.
(c) Insurers shall disclose the application of the rate reduction on each Declarations page during the period for which the rate reduction is applied.
(d) Insurers shall maintain separate defensive driving experience statistics until coding by statistical agents for persons receiving the discount is implemented.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 24 - DEFENSIVE DRIVING RATE REDUCTIONS › Section 11:3-24.4 - Application of defensive driving rate reduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insured may receive a rate reduction for successful completion of a defensive driving course provided he or she is the named insured or principal operator of an automobile insured under the policy or is an occasional operator whose experience is used to rate the policy.
(b) If the policy insures two or more automobiles, the rate reduction shall apply only to the automobile(s) principally operated or assigned to the person who has completed the defensive driving course. Only one rate reduction may be applied to an automobile on the policy.
(c) The rate reduction shall be applied for three years beginning with the next policy period after completion of the defensive driving course, as follows:
1. The rate reduction shall be applied if the driver completed the defensive driving course in the three year period immediately preceding the new business or renewal effective date of the policy.
2. The rate reduction shall not be applied during the three-year period beginning with the completion of the defensive driving course and ending with the new business or renewal effective date of the policy, if the driver who completed the defensive driving course accumulates four or more motor vehicle points or has his or her drivers license suspended for one of the reasons listed in N.J.A.C. 11:3-35.4(e)1.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 24 - DEFENSIVE DRIVING RATE REDUCTIONS › Section 11:3-24.5 - Procedure to obtain rate reduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Insurers may require the named insured on the policy to apply for the rate reduction by notifying the insurer of the successful completion of a defensive driving course.
(b) Insurers shall establish procedures to process and verify requests for rate reductions pursuant to this section based on:
1. The completion of a defensive driving course that appears on the driver record abstract. All drivers who have taken an approved defensive driving course will have the date the course was actually completed as the event date and one or more of the following event codes on their driver record abstract:
i. PDP-M-DDCC described as POINT CREDIT--DEFENSIVE DRIVING PROG used until July 1996, for drivers with zero points;
ii. DMV-M-DDCC described as DEFENSIVE DRIVING COURSE used after July 1996, for all drivers regardless of point accumulation, in addition to the two event codes in (b)1iii and iv below that are used if the driver had a point accumulation before taking the defensive driving course;
iii. DDP-Z-PC01 described as POINT CREDIT--DEFENSIVE DRIVING PROG used for drivers with one point;
iv. DDP-Z-PC02 described as POINT CREDIT--DEFENSIVE DRIVING PROG used for drivers with two or more points; or
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement 39:6A-5, as amended by P.L. 1995, c.407, by establishing procedures to be followed by treating medical providers to give timely notification of the commencement of medical treatment for injuries sustained in automobile accidents. The subchapter sets forth:
1. Time limits for the filing of notification of the commencement of treatment for PIP claims;
2. The actions to be taken upon failure to comply with the notification time limits, including reduction or denial of claim payments;
3. The factors to be considered in evaluation of a late notification; and
4. The rights of providers when payment is reduced or denied for failure to comply with the notification requirements.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.3 - Notification of commencement of treatment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When medical treatment is rendered for which a claim for payment will be made pursuant to the PIP coverage of a private passenger automobile insurance policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of the commencement of such treatment.
(b) In accordance with the PIP information provided by the injured party or the insured, notice shall be sent by the treating health care provider to the insurer at the address established by the insurer for the receipt of such notice.
(c) Insurers shall establish one address where notice must be sent by treating health care providers pursuant to these rules. Insurers shall provide this address, and may provide a facsimile transmission number, and E-mail address if any, on all insurance identification cards issued by the insurer after January 6, 1997.
(d) In accordance with the provisions of 11:3-25.1 0, insurers shall file with the Department the address, and may provide a facsimile transmission number, and E-mail address, if any, where notice of commencement of treatment should be sent. Insurers shall also include the name and telephone number of a contact person at the insurer for this purpose. Such information shall be added to a list of insurer addresses maintained by the Department.
(e) Notice sent to the address printed on a valid insurance identification card or on the Department's current list of addresses shall be presumed to have been sent to the proper address.
(f) Within 14 days after receiving notice of the commencement of treatment, the insurer shall notify the treating health care provider of the coverage status of the person receiving treatment. If the notice from the insurer states that the coverage status of the person receiving treatment is unknown, the insurer shall make a determination of coverage and provide written confirmation to the treating health care provider no later than 60 days from receipt of notice of commencement of treatment. Examples where the coverage status may not be known are when the injured person is not a named insured, principal or occasional operator, or is not otherwise listed as a resident of the insured household on the most recent information provided to the insurer by the named insured.
(g) The notice requirements set forth in (a) through (c) above and the eligible charge reductions contained in 11:3-25.5 shall not apply to secondary medical providers, except as noted in the definition of that term found in 11:3-25.2.
(h) In calculating the time for notice in (a) and (f) above, the day treatment begins or the day the insurer receives notice from the treating health care provider is not to be included. If the last day for providing notice falls on a Saturday, Sunday or legal holiday, the time runs to the next business day.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.4 - Content of notice and proof of receipt

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The treating health care provider shall send the written notice required by 11:3-25.3(a)  to the PIP insurer on either:
1. The "Notification of Commencement of Medical Treatment Form" found in Appendix A, appended to and incorporated by reference in this subchapter; or
2. A bill or invoice rendered by the treating health care provider that includes at a minimum the information required in the "Notification of Commencement of Medical Treatment Form" in Appendix A.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.5 - Late notification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In the event notice of commencement of medical treatment is made after 21 days, the insurer shall advise the treating health care provider in writing of the late notification and may reserve the right to reduce payment in accordance with (b) below.
(b) Where notice of the commencement of medical treatment is not timely provided in accordance with this subchapter, an insurer may apply the following reductions to the eligible charges:
1. 22 to 30 days after the commencement of treatment: 10 percent reduction.
2. 31 to 60 days after the commencement of treatment: 25 percent reduction.
3. 61 to 120 days after the commencement of treatment: 50 percent reduction.
4. 121 to 160 days after the commencement of treatment: 75 percent reduction.
5. 161 or more days from the commencement of treatment: 100 percent reduction.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.6 - Standards for adjustment of reduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Notwithstanding the reductions set forth in 11:3-25.5(b), insurers may choose to pay the full or a less reduced amount of an eligible charge based upon consideration of the following factors:
1. Whether the treating health care provider has previously provided untimely notice under this subchapter or has established a pattern of untimely notice;
2. The cost of medical treatment provided by the treating health care provider between the time treatment commenced, when notice was due and when it was provided;
3. The injured party was a pedestrian who did not have PIP coverage as the named insured or resident relative under another policy and the circumstances are such that additional time is necessary to identify the policy under which coverage is being provided;
4. Any potential adverse impact on the public; and
5. Such other factors as the insurer may determine.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.7 - Responsibility for payment

Current through Register Vol. 56, No. 14, July 15, 2024
Whenever an eligible charge has been reduced or denied pursuant to 11:3-25.5(b), the treating health care provider shall not seek to obtain payment directly from the insured or the person receiving treatment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.8 - Procedure for appeals

Current through Register Vol. 56, No. 14, July 15, 2024
A treating health care provider who fails to notify the insurer within 21 days and whose claim has been reduced or denied by the insurer pursuant to 11:3-25.5(b)  may, in the discretion of a judge of Superior Court, be permitted to refile such claim provided that the insurer has not been substantially prejudiced thereby. Application to the court for permission to refile a claim shall be made within 14 days of the receipt of the insurer's final determination of reduction or denial of payment and shall be made upon motion based upon affidavits showing sufficient reasons for the failure to notify the insurer within 21 days of the commencement of treatment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.9 - Reporting requirement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By February 5, 1997, every insurer shall file with the Department the address, facsimile number (if notice by facsimile is permitted) and E-mail address, if any, of the designated location for the filing of notice required under this subchapter. Insurers shall use Appendix B, appended to and incorporated by reference in this subchapter, to report the information required by this subsection.
(b) Insurers shall complete and file the information in Appendix B by January 1 of each year.
(c) Completed copies of Appendix B shall be submitted to:
Department of Banking and Insurance
Director of Public Affairs
PO Box 325
Trenton, New Jersey 08625-0325
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Section 11:3-25.10 - Compliance

Current through Register Vol. 56, No. 14, July 15, 2024
For treatments rendered between January 6, 1997 and July 6, 1997, all eligible charge reductions set forth in 11:3-25.5(b)  shall be reduced by 50 percent (for example, a 10 percent reduction shall be five percent, a 25 percent reduction shall be 12.5 percent, etc.).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
Notification of Commencement of Medical Treatment
(to be filed with insurer)
Name, address and phone number of Treating Health Care Provider:
.............................................................................
.............................................................................
Fax Number (optional) .......................................................
Name and address of patient:
Name and address of insured: (if
different)
......................................
......................................
......................................
......................................
......................................
......................................
......................................
......................................
Insurer Name: ..............................................................
Insurer Address:
.............................................................................
Policy No. ..................................................................
Date of accident/injury: ...................................................
Date of first treatment: ...................................................
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 25 - PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE PROVIDERS › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
Address for Notification of Commencement of Medical Treatment
Insurance Co. Name: ......................................................
NAIC Group #: .......................
NAIC Company #: .....................
Address established by insurer for the filing of the notification of
the commencement of PIP treatment by Treating Health Care Providers
Address:
.................................................................
.................................................................
.................................................................
Facsimile Number: ........................................................
E-mail: ..................................................................
Contact Person: ..........................................................
Phone: ...................................................................
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 26 - UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT › Section 11:3-26.1 - Claim information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Notice of intention to make a claim under 39:6-65 shall contain the following information:
1. The claimant's name, address, date of birth and social security number;
2. The time, date, location, municipality and county in which the loss occurred;
3. The identity of the operators and vehicles involved in the accident, including the name and address of the owner and operator and the license plate number of the vehicle;
4. Such witnesses to said accident as are then known;
5. A short description of the accident, including the claimant's role or position therein;
6. A description of the injuries then known, and attached thereto a medical certificate if then available. In any event the medical certificate shall be filed as soon as available;
7. A description of the damage sustained to property, and attached thereto an estimate of the cost of repairs if then available; and
8. The policy number of any insurance applicable to the accident, including the name and address of all insurance companies involved.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 26 - UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT › Section 11:3-26.2 - Claim filing; form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Notice of Intention to Make Claim under 39:6-65 may be filed on the form designated by the Unsatisfied Claim and Judgment Fund identified as a "Notice of Intention to Make Claim", incorporated herein by reference as Appendix A.
(b) A written notice to the Board in any other form that contains the information required by this section shall be acceptable.
(c) A notice of intention to make a claim that does not contain the items identified in 11:3-26.1(a)  1 through 8 shall be returned to the sender and deemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) for the purpose of complying with 39:6-65 and shall not toll the statute of limitations.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 27 - UNSATISFIED CLAIM AND JUDGMENT FUND BOARD › Section 11:3-27.1 - Uninsured's current financial status

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon review of a case by the Unsatisfied Claim and Judgment Fund Board's designee, if the designee does not have sufficient current information to determine whether or not the uninsured's installment payment is reasonable, a request will be addressed to the uninsured asking for a statement of current financial status.
(b) If the uninsured fails to furnish a completed statement of current financial status within a time period to be established by the executive director, the Unsatisfied Claim and Judgment Fund Board's designee will request the Director of Motor Vehicles to suspend the license and all registrations of the uninsured pursuant to 39:5-30 and 39.5-87, for failure to furnish this information.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimburseable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $ 10,000 or more submitted by licensed providers of health care services or claims of $ 25,000 or more by health care facilities; and requiring prior approval of claims for alterations to vehicles and residences. This subchapter also requires insurers to pursue the proper, alternative sources for reimbursement where such other sources of funds are available.
(b) This subchapter applies to all insurers authorized in this State to write the kinds of insurance specified in paragraphs d and e of 17:17-1. In accordance with 39:6-73.1, reimbursement for medical expense benefits may be sought from the Fund on account of personal injury to any one person in any one accident occurring on or after February 19, 1978.
(c)
									11:3-28.1 3 establishes standards for insurers to demonstrate diligent pursuit of any potentially responsible tortfeasor for the purpose of recovering PIP medical expense benefits paid on behalf of the injured party by the Fund. Insurers shall obtain reimbursement from the Fund for excess medical expense benefit payments once they comply with the standards established herein. The purpose of these provisions are to contain costs for automobile insurance in this State. Accordingly, consistent with this purpose and 39:6A-9.1, for accidents occurring outside this State, insurers are expected to assert appropriate legal remedies to pursue recovery actions against potentially responsible tortfeasors, consistent with the legal rights and remedies asserted by the injured party.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.3 - Report of claims when the carrier has paid at least $ 50,000 for medical expense benefits

Current through Register Vol. 56, No. 14, July 15, 2024
In cases where the potential exposure to the automobile liability insurer exceeds $ 75,000, the insurer shall report on UCJF Form 1(321) (incorporated herein by reference as Form 1 in Appendix A) whenever medical expense benefits in a total amount of $ 50,000 have been paid on account of personal injury to any one person in any one accident.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.4 - Notice of change in the amount of reserves

Current through Register Vol. 56, No. 14, July 15, 2024
Whenever an automobile liability insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount of $ 50,000, said insurer shall notify the Fund of any changes in the amount of reserves established for payment of the claim or closing of the file.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.5 - Supplemental forms to be submitted to the Fund

Current through Register Vol. 56, No. 14, July 15, 2024
(a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount in excess of $ 75,000. Such form together with UCJF Form 3(323) (incorporated herein by reference as Form 3 in Appendix A) shall be filed each quarter thereafter that the insurer seeks reimbursement.
(b) Any office of an insurer seeking reimbursement of funds from the UCJF for personal injury protection medical expense must also complete and file with the UCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporated herein by reference as Form 4 in Appendix A).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.6 - Insurer's continuing obligation to investigate claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An automobile liability insurer shall be required to discharge its duty of investigating claims where the potential exposure to the insurer exceeds $75,000. Said insurer's duty and obligation with regard to claim handling shall exist and continue to exist notwithstanding this rule. The Executive Director may direct such investigations as often as he or she deems necessary. All expenses relating to the investigation of claims, including expenses for medical examinations, file maintenance and cost containment measures, are the responsibility of the automobile liability insurer.
(b) The failure to properly discharge the duty of investigating a claim may result in the imposition of a penalty, to be determined by the Board's designee against the insurer's request for reimbursement.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.7 - Reimbursement of excess medical expense benefits paid by insurers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim payments of $ 20,000 or more. For claim payments of less than $ 20,000, insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefits either quarterly or at the close of the calendar year in which such expenses are incurred. Insurers shall not be reimbursed for interest, attorney fees or punitive damages.
1. Regardless of the size of a claim payment for excess medical expense benefits, an insurer shall submit to the Fund a request for reimbursement within a period of two years from the date of payment by the insurer of the excess medical expense benefit for which reimbursement is sought.
2. Failure to comply with the requirements set forth in (a)1 above shall result in a denial by the Fund of the reimbursement request which was omitted from the quarterly submission.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.8 - Audits

Current through Register Vol. 56, No. 14, July 15, 2024
Upon request of the Fund, the insurer(s) shall present for audit at the direction of the Executive Director at a New Jersey location all policy and claim records on which notice of potential for payment of excess medical expense benefits have been submitted.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.9 - Reporting of losses for personal injury protection payments in excess of $ 75,000

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of completing page 14, Exhibit of Premiums and Losses, of the annual statement filed pursuant to 17:23-1, the insurer shall include the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments (lines 19.1 and 19.3), including those in excess of $ 75,000. Insurers shall also provide a footnote on page 14 that indicates the amount of losses reported, excluding losses from payments of private passenger automobile and commercial automobile personal injury protection payments in excess of $ 75,000.
(b) For purposes of completing Schedule F of the annual statement, insurers shall consider the assumption and reimbursement by the Fund of private passenger automobile and commercial automobile personal injury protection payments in excess of $ 75,000 as a reinsurance transaction. Insurers shall consider assessments paid to the UCJF pursuant to 39:6-63 based on the insurer's premiums for private passenger automobile liability insurance (including PIP) and commercial automobile liability insurance (including PIP) as ceded premium, pro rated for the appropriate line of business on which the assessment was based.
(c) Insurers shall comply with the provisions of this section beginning with the annual statement due March 1, 1994 (covering the calendar year ended December 31, 1993). For purposes of completing the annual statement due March 1, 1993 (covering the calendar year ended December 31, 1992), insurers shall file by no later than July 1, 1993 a supplemental page 14 and schedule F of the annual statement in accordance with the provisions of this section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.10 - Insurers' obligations to investigate and audit bills for medical benefits

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000 and an on-site audit where such claims are equal to or in excess of $50,000.
1. Failure of an insurer to complete an audit in accordance with these rules shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.
2. Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter.
3. An insurer shall conduct any such audit to determine whether the level of care, need and charges are appropriate.
4. An insurer may pay 80 percent of the provider's bill prior to completion of the initial on-site audit. The remaining amount due, if any, shall be paid following completion of the insurer's audit.
5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of the audit; and
6. Whenever a change in services occurs such as, but not limited to, the level of care, the daily room rate or additional charges, an insurer shall conduct an on-site audit and shall provide the audit and auditor's statement to the Fund with the next reimbursement request.
7. All other audits shall be conducted prior to payment to the health care facility and may be performed on a pre-screen basis as set forth in (e) below.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.11 - Modifications to vehicles

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used for the benefit of the claimant, the cost of which may be reimbursed by the Fund.
(b) An insurer shall submit a written request to the Fund, including a Van Purchase and Modification Agreement seeking approval of modifications which are equal to or in excess of $1,000, within 30 days of a claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary care physician including:
i. Where the claimant is the operator of the vehicle, current findings on the claimant's physical ability to drive and a copy of the claimant's current driver's license;
ii. A brief analysis of the medical necessity and medical purpose for the requested modifications;
iii. A description of the purpose for which the vehicle will be used; and
iv. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.12 - Modifications to a claimant's residence

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the Fund.
(b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in excess of $ 10,000, within 30 days of a claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary care physician including:
i. A brief analysis of the medical necessity for the requested modifications; and
ii. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident;
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.13 - Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Fund shall reimburse insurers for paid medical expense benefit claims if an insurer demonstrates that it has diligently pursued all potentially responsible tortfeasors within the time prescribed at 39:6A-9.1, or any other applicable limitation period.
1. An insurer shall demonstrate, in accordance with (c) below, that it has diligently pursued any potentially responsible tortfeasor to obtain reimbursement of PIP medical expense benefit claim payments made by the insurer from the Fund.
2. Where the insurer has failed to diligently pursue any potentially responsible tortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reimbursements on that claim. The Fund shall also be entitled to recover from the insurer any reimbursement payments already made to the insurer on that claim, after notice and opportunity for a hearing in accordance with the Administrative Procedure Act, 52:14B-1 et seq. and Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a potentially responsible tortfeasor or a tortfeasor.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.14 - Insurer's responsibility upon assignment of an uninsured motorist claim

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which:
1. Acknowledges receipt of the assignment and the accompanying instruction sheet; and
2. Provides the names and telephone numbers of the case handler or manager, the claim investigator and the claim adjuster.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
Form #1
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New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
AMORTIZATION FORMULA
The Fund shall evaluate the cost effectiveness of modifications to a residence and shall establish an amortization schedule based on information submitted to the Fund by the insurer. The insurer shall file with the Fund the information in categories (a) through (d) below. This information shall be accompanied by the documentation which supports the information in those categories. The factors which shall be considered by the Fund include:
(a) Cost of modifications;
(b) Annual cost of home care, including but not limited to, nursing care, therapy, transportation for medical treatment and medical supplies;
(c) Life expectancy of the injured person;
(d) Annual cost of other residential care alternatives;
(e) Monthly amount amortized; and
(f) Term of amortization in months.
1. The formula which the Fund shall evaluate to determine the cost effectiveness of requested home modifications is as follows:
(a + (b x c)) < (d x c)
The Fund shall only approve modifications where the above formula applies.
2. The formula to determine the amount to be amortized monthly is as follows:
(d - b)/12 = e
3. The formula to determine the term of the amortization schedule is as follows:
a/e = f
The following examples demonstrate how the formulas shall be applied:
Click here to view image.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Appendix C

Current through Register Vol. 56, No. 14, July 15, 2024
UNSATISFIED CLAIM AND JUDGMENT FUND RECOVERY CERTIFICATION
Click here to view image.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 29 - MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE › Section 11:3-29.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every policy of automobile insurance and motor bus insurance issued in this State shall provide that the automobile insurer's limit of liability for medically necessary expenses payable under PIP coverage, and the motor bus insurer's limit of liability for medically necessary expenses payable under medical expense benefits coverage, is the fee set forth in this subchapter or the usual, customary and reasonable fee, whichever is less.
(b) This subchapter implements the provisions of 39:6A-4.6 to establish medical fee schedules on a regional basis for the reimbursement of health care providers providing services or equipment for medical expense benefits for which payment is required to be made by automobile insurers under PIP coverage and by motor bus insurers under medical expense benefits coverage.
(c) This subchapter applies to all insurers who issue policies of automobile insurance containing PIP coverage and policies of motor bus insurance containing medical expense benefits coverage.
(d) This subchapter does not apply to the following:
1. Other coverages contained in an automobile or motor bus insurance policy such as coverage for bodily injury liability;
2. Any other kind of insurance including health insurance, even when the health insurer may be required pursuant to its health insurance contract to pay benefits to, or on behalf of, a person who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile or motor bus, or as a pedestrian, caused by an automobile or motor bus or an object propelled by or from an automobile or motor bus;
3. Medical services or equipment provided outside of the geographic boundaries of New Jersey except as set forth in 11:3-29.4(d)2; and
4. Inpatient services provided by acute care hospitals, trauma centers, rehabilitation facilities, other specialized hospitals, residential alcohol treatment facilities and nursing homes, except as specifically set forth in this subchapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 29 - MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE › Section 11:3-29.3 - Regions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Regions in Appendix, Exhibit 1, Physicians' Fee Schedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, are as follows:
1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 077, 080, 081, 082, 083, 084, 086 and 087. The South Region also includes: 08501, 08505, 08510, 08511, 08514 through 08527, 08533 through 08535, 08540 through 08550, 08554, 08555 and 08560 through 08562.
2. North Region consists of Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren counties, which are comprised of the following three- and five-digit zip codes in New Jersey: 070, 071, 072, 073, 074, 075, 076, 078, 079, 088 and 089. The North Region also includes: 08502, 08504, 08512, 08528, 08530, 08536, 08551, 08553, 08556 through 08559 and 08570.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 29 - MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE › Section 11:3-29.4 - Application of medical fee schedules

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Nothing in this subchapter shall compel the PIP insurer or a motor bus insurer to pay more for any service or equipment than the usual, customary and reasonable fee, even if such fee is well below the automobile insurer's or motor bus insurer's limit of liability as set forth in the fee schedules. Insurers are not required to pay for services or equipment that are not medically necessary.
1. The fees for physicians' services in subchapter Appendix, Exhibit 1, the provisions in (f)1 through 7 below and the non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to trauma services at Level I and Level II trauma hospitals. Bills for services subject to the trauma services exemption shall use the modifier "-TS".
2. The non-physician facility fees in subchapter Appendix, Exhibit 7 shall not apply to services provided in hospital emergency rooms. The bills for these services shall use the modifier "-ER".
3. The physician fees for surgical services (CPT 10000 though 69999) provided in emergency care in acute care hospitals that are not subject to the trauma care exemption shall be reimbursed at 150 percent of the physicians' fees in subchapter Appendix, Exhibit 1. The bills for these services shall use the modifier "-ER".
4. Except as provided in (a)1 through 3 above, the fees in Appendix, Exhibits 1 through 7 apply regardless of the site of service.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 29 - MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE › Section 11:3-29.5 - ASC facility fees; hospital outpatient surgical facility fees

Current through Register Vol. 56, No. 14, July 15, 2024
(a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including:
1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;
2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care;
3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment;
4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see:
www.cms.gov/ASCPayment/ASCRN/list.asp
, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: https://
http://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_D1.pdf
) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF;
5. Administrative, recordkeeping, and housekeeping items and services;
6. Blood, blood plasma, platelets, etc.;
7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and
8. Implantable DME and prosthetics.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 29 - MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE COVERAGE › Section 11:3-29.6 - Balance billing prohibited

Current through Register Vol. 56, No. 14, July 15, 2024
No health care provider may demand or request any payment from any person in excess of those permitted by the medical fee schedules and this subchapter, nor shall any person be liable to any health care provider for any amount of money that results from the charging of fees in excess of those permitted by the medical fee schedules and this subchapter.