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New Jersey Auto Reform
New Jersey Auto Reform
 
The Automobile Insurance Reduction Act of 1998 ("The Auto Reform Act") became operational on March 22, 1999. The two most significant features to the Act are:
  • A reduction of insurance premiums charged by carriers in New Jersey.
  • Personal Injury Protection (PIP) benefits which shall provide for reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident.
The rules and changes described in The Auto Reform Act will become effective when existing policies are renewed, or when new policies are written. For information specific to individual insurance policies (rates, effective dates, coverage limits, policy terminology, etc.) policyholders are referred to their agents or automobile insurance carrier.
Key issues of The Auto Reform Act:
  • Covered injured persons may seek treatment from a wide array of health care providers. The only requirement is that the health care facilities and practitioners must be licensed or certified by the appropriate state authorities.
  • The insurance carriers may utilize the services of companies like CHN Solutions to help determine the medical necessity and appropriateness of the care being provided to the injured persons.
  • No pre-certification is required for services provided during the first 10 (ten) days following the covered motor vehicle accident. However said care may be subject to review and bill audit. If treatment, diagnostic tests or services will be necessary after the 10th(tenth) day following the covered accident, pre-certification review will be necessary for specified services.
  • A list of diagnostic tests and treatment services (EXHIBIT B) will require pre-certification review. When the injured person's treating provider decides to order or perform services identified by The Auto Reform Act, approval to perform said services must be given prior to the performance of the diagnostic test or treatment.
  • Providers who treat covered injured persons for neck and back injuries may need to adjust their treatment plans to comply with the Care Paths that have been developed for N.J.A.C. 11:3-4. The Care Paths address treatment and services most frequently provided to patients with neck and back injuries.
  • When a provider obtains early certification of the treatment plan for neck and back injuries (during the first 28 days following the covered auto accident), submitted bills will be reimbursed without review or audit, penalties will not be applied, and the insured will not be responsible for penalty co-payments for the certified services. (Some policy co-payments may still apply)
  • If the treating provider or the injured person fails to comply with decision point review requirements or to obtain pre-certification for the tests and/or treatments, the provider may be subject to a 50% reduction in reimbursement for the service, even though the test or service may be medically necessary. The injured person may be financially responsible for the balance of payments to the provider. If the test or treatment is determined NOT to be medically necessary in regard to the injury sustained in the covered automobile accident, NO REIMBURSEMENT will be made to the treating provider by the carrier. The injured person may be financially responsible for the balance of payments. It is in the best interest of the injured person to ensure that the treating provider cooperates with the pre-certification process described by The Auto Reform Act. We urge all injured persons who seek medical care to discuss the pre-certification process with their treating health care providers.
The Voluntary Utilization Provision allows the insurance carriers to access CHN Solutions' networks of:
If an insured utilizes a conveniently located network provider for Durable Medical Equipment over $50, Diagnostic Imaging and Electro diagnostic Testing, 30% co-pay ($10 for prescription drugs) will be waived.
In summary, the Auto Reform Act of 1998 has focused on 3 issues of interest to the public:
  1. A reduction in the automobile insurance premiums designed to provide relief to the consumers.
  2. Establish rules and guidelines so that only medically necessary care and treatment is provided to persons injured in automobile accidents.
  3. Help combat insurance fraud and abuse.

Definition of Terms

CARE PATHS
A recommended extensive course of care, based on professionally recognized standards, directed toward spinal (neck and back) injuries. See Identified Injuries (Exhibit A).
 
CASE MANAGEMENT
A coordinated set of utilization and cost management activities focused on the treatment plan for patients with complex needs (requiring multiple services and/or substantial health care resources and support) to achieve quality, cost effective outcomes.
 
CERTIFICATION
Determination that an admission, extension of hospital stay, or other health care service has been reviewed, and based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care or effectiveness under the auspices of the applicable health benefit plan.
 
CLINICAL/MEDICAL REVIEW CRITERIA
The decision rules, medical protocols or guidelines used to determine medical necessity and appropriateness of care.
 
CONCURRENT REVIEW
Utilization review conducted during a patient's hospital stay or course of treatment.
 
DECISION POINT REVIEW
During the course of treatment of patients with identified injuries, the proposed diagnostic tests and treatments, as described in the Care Paths, must be evaluated and reviewed at certain intervals called decision points. The treating provider must submit to CHN Solutions sufficient information to support the request to certify these diagnostic tests and treatment (as listed in EXHIBIT B). Decision point review is pre-certification review specific to services described in the Care Paths.
 
EMERGENCY CARE
Medically necessary treatment provided to an injured person at a hospital within 120 hours (5 days) after the accident. The injury or medical condition should manifest such severe symptoms that absence of immediate attention could reasonably be expected to result in death, impairment or serious bodily dysfunction.
 
IDENTIFIED INJURIES
Injuries that result from a covered auto accident which involve the cervical spine (neck), thoracic spine (upper back) and lumbo-sacral spine (low back). See Identified Injuries (Exhibit A).
 
MEDICAL NECESSITY
The medical treatment or diagnostic tests that are consistent with clinically supported symptoms, diagnosis or indications of the injured person. The treatment is at the most appropriate level, is not primarily for the convenience of the injured person or the provider, and in accordance with the standards of the profession.
 
PRE-CERTIFICATION REVIEW
Utilization review conducted prior to a patient's admission or other course of treatment.
 
PROVIDER
A licensed (or certified) health care facility, physician or other health care professional who delivers health care services.
 
RECONSIDERATION
A request by telephone for additional review of CHN Solutions' determination not to certify, performed by the physician who reviewed the original decision, based on submission of additional information and/or a physician to physician discussion. See Reconsideration Process.
 
TREATING PROVIDER
The physician or other health care provider with primary responsibility for the care provided to a patient in a hospital or other health care facility, and/or the health care provider who prescribes treatment for a patient.
 
TREATMENT PLAN
Specific medical, surgical, chiropractic, acupuncture or psychiatric procedures used to improve the signs and symptoms associated with injuries sustained in automobile accidents, e.g., physical therapy, surgery, administration of medication, diagnostic tests and procedures, etc. See Treatment Plan Request Form.
 
UTILIZATION REVIEW
Evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures and facilities under the auspices of the applicable health benefit plan.
 

Identified Injuries (EXHIBIT A)

722.0 Displacement of cervical intervertebral disc without myelopathy.
722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy.
722.10 Displacement of lumbar intervertebral disc without myelopathy.
722.11 Displacement of thoracic intervertebral disc without myelopathy.
722.2 Displacement of intervertebral disc, site unspecified, without myelopathy.
722.71 Intervertebral disc disorder with myelopathy, cervical region.
722.72 Intervertebral disc disorder with myelopathy, thoracic region.
722.73 Intervertebral disc disorder with myelopathy, lumbar region.
728.0 Disorders of muscle, ligament and fascia.
728.85 Spasm of muscle.
739.0 Non-allopathic lesions-not elsewhere classified.
739.1.1 Somatic dysfunction of cervical region.
739.1.2 Somatic dysfunction of thoracic region.
739.3 Somatic dysfunction of lumbar region.
739.4 Somatic dysfunction of sacral region.
739.8 Somatic dysfunction of rib cage.
846.0 Sprains and strains of sacroiliac region.
846.1 Sprains and strains of lumbosacral (joint, ligament).
846.2 Sprains and strains of sacrospinatus (ligament).
846.3 Sprains and strains of sacrotuberous region.
846.8 Sprains and strains of other specified sites of sacroiliac region.
846.9 Sprains and strains, unspecified site of sacroiliac region.
847.0 Sprains and strains of neck.
847.1 Sprains and strains, thoracic.
847.2 Sprains and strains, lumbar.
847.3 Sprains and strains, sacrum.
847.4 Sprains and strains, coccyx.
847.9 Sprains and strains of back, unspecified site.
922.3 Contusion of back.
922.31 Contusion of back, excludes interscapular region.
922.33 Contusion of back, interscapular region.
953.0 Injury to cervical root.
953.2 Injury to lumbar root.
953.3 Injury to sacral root.

CHN Solutions Pre-certification List (EXHIBIT B)

Pre-certification requirements will become effective 10 days after the date of the accident. Precertification does not include emergency care and treatment at any time. As per N.J.A.C. 11:3-4 and the patient's/insured's insurance policy, the following items will require pre-certification:
Diagnostic Tests that are subject to Decision Point Review regardless of diagnosis:
  1. Brain audio evoked potentials (BAEP),
  2. Brain evoked potentials (BEP),
  3. Computer assisted tomograms (CT, CAT scan),
  4. Dynatron/cybex station/cybex studies,
  5. Electroencephalogram (EEG),
  6. H-reflex studies,
  7. Magnetic resonance imaging (MRI),
  8. Needle electromyography (EMG),
  9. Nerve conduction velocity (NCV),
  10. Somatosensory evoked potential (SSEP),
  11. Sonogram/ultrasound,
  12. Videofluroscopy,
  13. Visual evoked potential (VEP)
  14. Brain Mapping
  15. Thermogram/Thermography
Services that require Pre-Certification:
  1. Non-emergency Inpatient and Outpatient Hospital Care
  2. Non-emergency surgical procedures,
  3. Durable medical equipment including orthotics and prosthetics costing greater than $50, or rental greater than 30 days,
  4. Outpatient Care: to include follow-up evaluations for soft tissue/disc injuries of the injured person's neck and back and related structures not included within diagnoses covered by the Care Paths,
  5. Extended care and rehabilitation,
  6. Home health care,
  7. Infusion therapy,
  8. Outpatient psychological/psychiatric testing and/or services,
  9. All physical, occupational, speech cognitive or other restorative therapy, or body part manipulation except that provided for Identified Injuries in accordance with Decision Point Review; and
  10. All pain management services except that provided for Identified Injuries in accordance with Decision Point Review,
  11. Non-emergency dental restoration

CHN Solutions Pre-certification Process

  1. After the claim has been reported to the insurance carrier, and coverage has been confirmed, a claim number will be assigned to the case.
  2. The injured person will be contacted by the carrier in order to explain the pre-certification process. The treating provider will be identified.
  3. CHN Solutions will contact the treating provider. (See "Dear Dr." letter) If continued treatment is indicated, a Voluntary Comprehensive treatment plan (to include services in EXHIBIT B) will be requested of the treating provider. During the process of pre-certification, CHN Solutions may request reports of diagnostic procedures, consultations, progress notes, and various other records. An initial diagnosis will be requested from the provider.
  4. CHN Solutions will apply nationally recognized clinical/medical review criteria to assist with the determination process. CHN Solutions will certify only treatment that appears to be medically necessary.
  5. When an initial determination is made to certify, notification will be provided by telephone to the provider and the facility within three (3) days of receipt of request. Written confirmation will be provided to the patient (or representative), the insurance carrier, physician, and when indicated, the facility. Facsimile transmission of the determination will be made when expeditiously indicated.
  6. For procedures that require overnight confinement, certification will include the procedure and estimated length of stay. The continued stay in the treating facility will be subject to concurrent utilization review.
  7. If medical criteria are not met, and CHN Solutions is unable to certify the request, the treating/ordering provider, and the facility rendering the service will be contacted via telephone within one (1) business day of the determination of non-certification. A CHN Solutions Physician Advisor will make all denial determinations and will be available to discuss the case with the treating/ordering provider (reconsideration).
  8. If CHN Solutions is unable to certify a surgical procedure, CHN Solutions will assist the patient to schedule a second surgical opinion or independent medical examination, at the expense of the insurance carrier.
  9. If the course of treatment continues over a prolonged period of time, or if the treatment becomes more complex and complicated, CHN Solutions may intensify their involvement with the case to help coordinate the various medical services prescribed for the patient (case management).
  10. Although emergency care does not require pre-certification, hospital admissions that extend beyond the tenth post-accident day will be subject to concurrent utilization review. Provider charges (physician and hospital) for the treatment provided during the first 10 post-accident days also may be subject to retrospective bill audit.
Four facets of the pre-certification process of the Auto Reform Act require emphasis:
  • When a treating provider participates in the voluntary pre-certification process, all bills submitted, when consistent with pre-certified services, will be paid without utilization audit. Continued participation in the pre-certification process for all requested services will ensure payment without the need for utilization audit.
  • When the treating provider participates in the voluntary pre-certification process penalty co-payments may not apply and some decision point review requirements can be waived or extended.
  • When the insured utilizes the voluntary network for electro diagnostic, diagnostic radiology, pharmacy and durable medical equipment, policy co-payments which specifically refer to these services will be waived.
  • When the treating provider accepts assignment of benefits he/she agrees to follow the decision point/pre-certification requirements and agrees to not balance bill for reductions which are made as a result of non-compliance to the policy rules.

CHN Solutions' Reconsideration Process

  1. When CHN Solutions is unable to certify, or renders a determination not to certify an admission, hospital stay, treatment plan, diagnostic test or other service, the attending or ordering provider:
    • Will be notified by telephone of the determination, which will be confirmed in writing
    • May request the clinical criteria utilized to make the determination
    • Will have the opportunity to request reconsideration by the physician advisor who made the initial determination
  2. The attending or ordering provider may initiate the reconsideration request by telephoning CHN Solutions at 1-800-293-9795.
  3. The reconsideration will occur within three (3) business days of the receipt of the request. It will be conducted between the attending physician or other ordering provider and the CHN Solutions Utilization Management Physician Advisor.
  4. When, during the course of generating a review determination, it becomes necessary for the CHN Solutions Physician Advisor to refer the case to a specialist-consultant on CHN Solutions Medical Advisor Committee, the specialist-consultant (or one of like specialty) will be available to participate in the reconsideration process.

Provider Appeal Process

  1. When reconsideration does not resolve a difference of opinion, the attending or ordering provider may submit the case for appeal through the Personal Injury Protection Dispute Resolution process.
  2. CHN Solutions will inform the physician or other ordering provider of his/her right to initiate an appeal and the procedure to do so when the review determination has been made. The appeal may be made to a state certified MRO through the American Arbitration Form at (732) 271-6100. Forms, rules and procedures are available on the web at: www.nj-info@arb-forum.com.

Dispute Resolution Process

If a disagreement arises in regard to PIP benefits or coverage, any party involved with this process (including the insured, the injured person (or his/her representative), treating providers, the insurance carrier, etc.) may request a resolution of the dispute. The request for dispute resolution should be made in writing. Copies of all pertinent records and information should accompany the request. The request should be made in accordance with New Jersey law or regulation and may include review by a medical review organization. (www.nj-info@arb-forum.com).
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