As of July 11, 2006, certain laws have changed regarding handling of claims, claims payment appeals, prior authorization processes, utilization management (UM) appeals rights and obligations, and information about clinical guidelines and claims submissions procedures that carriers must have readily available for health care providers. The existing law was amended and supplemented by L. 2005, c. 352 (Chapter 352).
The Department does not yet have rules in place to implement the requirements of Chapter 352. However, the Department has begun issuing bulletins to provide guidance to both carriers and health care providers. The Department has also begun issuing forms to help carriers and health care providers comply with the new law. This includes:
Bulletin 06-16: P.L. 2005, C. 352 – Health Claims Authorization, Process and Payment Act – Forms, Effective Date, and an Update on Arbitration
- Consent and Authorization (For UM Appeals and Arbitration)/Notice of Revocation of Consent (For UM Appeals)
- Application to Appeal a Claims Determination
Bulletin 06-17: P.L. 2005, C. 352 – Health Claims Authorization, Process and Payment Act (HCAPPA) – Forms
- Independent Health Care Appeals Program Application
- Notices of Intent to File a UM Appeal – Stage 1, Stage 2, and Stage 3
Bulletin 07-14: P.L. 2005, C.352 – Health Claims Authorization, Processing and Payment Act (HCAPPA) – Arbitration Program
You can find links to the forms and instructions below, or with the bulletins, or you can access the forms and instructions on the Department’s Industry Forms/Applications Online page directly. |
Claims Payment Dispute Arbitration NEW |
A new health claims binding arbitration program for doctors, hospitals and other medical service and equipment providers is now available. The Program for Independent Claims Payment Arbitration (PICPA) is accepting applications and is operated for the Department by MAXIMUS, Inc.
On or about July 2, 2007, parties with claims eligible for arbitration may complete an application accessible online at https://njpicpa.maximus.com, and submit the application, together with required review and arbitration fees, to the PICPA.
The completed online applications can be printed and/or saved for the applicant's own records. Supporting documentation may be submitted online, faxed or mailed using the case number generated through the online submission process.
Fees must be submitted by mail at this time and must also include the case number. An application for arbitration will not be considered until the required application fees are received.
More information on claims eligibility... |
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The following instructions are designed to help health care providers or carriers, as appropriate, utilize the forms on a routine basis. (Please note, the Department of Health and Senior Services has posted some translations of some of the forms on the Office of Minority and Multicultural Health web page.)
| Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims |
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| Notice of Intent to Appeal an Adverse UM Determination – Stage 1 |
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| Notice of Intent to Appeal an Adverse UM Determination – Stage 2 |
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| Notice of Intent to Appeal an Adverse UM Determination – Stage 3 |
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| Application for the Independent Health Care Appeals Program |
- MS Word (92K) or PDF (182K) (This form is self-explanatory, and contains instructions regarding the filing fee and additional documentation that should be included with the application.)
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| Health Care Provider Application to Appeal a Claims Determination |
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| Health Care Provider Application to Appeal a Claims Determination |
- MS Word (91K) or PDF (109K)
The generic version of this form is intended primarily for use by non-participating providers, and is available through the Department of Banking and Insurance’s web site for download only. The form is self-explanatory, and currently contains instructions regarding additional documentation that may be required with the application. Health care providers using this form who have questions regarding submission of specific information should contact the carrier with whom they intend to file the internal claim payment appeal. DO NOT SUBMIT THE FORM TO THE DEPARTMENT OF BANKING AND INSURANCE – IT WILL NOT BE PROCESSED!
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| A claim is eligible for arbitration if: |
| 1. |
The claim was submitted to an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, prepaid prescription service organization, or its agent, including an organized delivery system (ODS) or a third party administrator (TPA), for payment under a health benefits plan issued in this State. Claim disputes submitted to a self-funded entity, the State Health Benefits Program, a dental service corporation, or a dental plan organization (DPO) are not eligible for resolution through the PICPA; |
| 2. |
The claim arises from health care services rendered on or after July 11, 2006; |
| 3. |
The health care provider appealed the denied claim to the carrier by submitting the Health Care Provider Application to Appeal a Claims Determination available above to access the carrier’s internal claims appeal process; |
| 4. |
The carrier’s internal claims appeal process was completed, or the carrier failed to comply with the processing and review timeframes with respect to the claim and the health care provider has documentation supporting that contention; |
| 5. |
When aggregating claims (for the purpose of reaching the minimum $1,000 dispute threshold), a health care provider aggregates claims by carrier and covered person or by carrier and CPT code; and |
| 6. |
The health care provider timely submits the application for arbitration and the appropriate fees. |
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