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Home > Insurance Division > Implementation of P.L. 2005, C. 352
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Changes in Health Care Claims Handling,
Prior Authorization and
Utilization Management Appeals
(Implementation of P.L. 2005, C. 352) |
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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 P.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 10-32: P.L. 2005, c. 352 – Health Claims Authorization, Processing and Payment Act (HCAPPA) – Change of Health Care Provider Application to Appeal a Claim Determination Form NEW
- Health Care Provider Application to Appeal a Claim Determination Form (Carrier Modifiable Form) - MS Word or PDF
- Health Care Provider Application to Appeal a Claim Determination Form (Generic Version) - MS Word or PDF
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| Prior Bulletins |
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 |
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| Claims Payment Dispute Arbitration |
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://dispute.maximus.com/nj/indexNJ, 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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| 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. |
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| Questions and Answers |
The Department of Banking and Insurance is providing a series of questions and answers that may be helpful for interested parties. The questions have been separated into categories for easier reference. Some questions appear in more than one category because of overlap in the subject matter. Please note the following about the responses:
- References to “carrier” throughout include any subcontractor of a carrier that performs the referenced function on behalf of the carrier.
- Unless indicated otherwise, responses do not apply to self-funded plans, to policies issued and delivered in a state other than New Jersey, or to limited benefits plans that do not provide hospital or medical expense benefits.
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| Chapter 352-related Forms and Instructions |
The following instructions are designed to help health care providers or carriers, as appropriate, utilize the forms on a routine basis.
| 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 (and Medicaid version) |
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Health Care Provider Application to Appeal a Claims Determination
(Carrier Modifiable Form) |
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Health Care Provider Application to Appeal a Claims Determination
(Generic Form) |
- MS Word or PDF
The generic version of this form 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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| Claims Payment Dispute Arbitration |
| To File an Arbitration Request online: https://dispute.maximus.com/nj/indexNJ |
- Selected Arbitration Decisions
- Bulletin 07-14 (PDF) (To providers, carriers and payers subject to P.L. 2005, c.352, and other interested parties - Health Claims Authorization, Processing and Payment act (HCAPPA) – Arbitration Program
- Program for Independent Claims Payment Arbitration (PICPA) Monthly Reports:
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| A claim is eligible for arbitration if: |
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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; |
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The claim arises from health care services rendered on or after July 11, 2006; |
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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; |
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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 appeal and the health care provider has documentation supporting that contention; |
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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 |
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The health care provider timely submits the application for arbitration and the appropriate fees. |
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| Note: Initially, applications can only by submitted online. Providers wishing to submit applications by mail should contact MAXIMUS using the contact information on their web site, https://dispute.maximus.com/nj/indexNJ. |
