BULLETIN No. 01-13

TO: ALL INSURERS SEEKING UCJF REIMBURSEMENT OF PERSONAL INJURY PROTECTION MEDICAL EXPENSES

FROM: KAREN L. SUTER, COMMISSIONER

RE: UNSATISFIED CLAIM AND JUDGMENT FUND: N.J.A.C.: 11:3-28.10(a)

All insurers, in cases where the claim is equal to or is in excess of $25,000, are reminded of the provisions of N.J.A.C. 11:3-28.10(a) which requires that:

  1. Insurers must conduct an investigation and on-site audit of claims submitted by the health care facility.

  2. Insurerís initial on-site audit for charges submitted by a health care facility shall determine whether the level of care, need and charges are appropriate.

  3. Insurers may only pay 80 percent of a providerís bill prior to completion of the initial on-site audit.

  4. Insurers shall conduct annual on-site audits at 12-month intervals following the initial on-site audit.

  5. Insurers shall conduct additional on-site audits whenever a change in services occurs (e.g., level of care, change in daily room rate, or additional charges).

  6. Insurers failing to comply with the on-site audit requirements will receive a 20 percent reduction by the Fund of the unaudited, reimbursable bill filed by the insurer.

The Department has observed some confusion concerning these audit requirements and is taking this opportunity to eliminate any misunderstanding regarding the application of these regulations that require actual on-site audits as described above.

 

 

9/6/2001 /s/ Karen L. Suter, Commissioner