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:
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.
- Insurers must conduct an investigation and on-site audit of claims submitted by the health care facility.
- 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.
- Insurers may only pay 80 percent of a providerís bill prior to completion of the initial on-site audit.
- Insurers shall conduct annual on-site audits at 12-month intervals following the initial on-site audit.
- 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).
- 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.
9/6/2001 /s/ Karen L. Suter, Commissioner