Dear PROVIDER'S NAME:

The patient noted above was involved in a motor vehicle accident (MVA). We have been informed that he/she will receive treatment with you. Pursuant to N.J.A.C. 11:3-4, you are required to provide us with notification for certain tests you may order, or services you may perform on the patient. As described more fully below, this notification is provided in connection with Decision Point Review and Pre-Certification. CHN Solutions has been contracted by INSURANCE CARRIER to be the Utilization Review Organization involved with the Decision Point Review/Pre-Certification process. Decision Point Review/Pre-Certification not apply until after the 10th day following the MVA and does not apply to Emergency Care.

DECISION POINT REVIEW

Pursuant to N.J.A.C. 11:3-4, the New Jersey Department of Banking and Insurance has published standard courses of treatment, Care Paths, for soft tissue injuries of the neck and back, collectively referred to as the Identified Injuries. (For a list of Identified Injuries by ICD-9 codes, see Exhibit A.) N.J.A.C 11:3-4 also establishes guidelines for the use of certain diagnostic tests. The Care Paths provide that treatment be evaluated at certain intervals called Decision Points. On the Care Paths, Decision Points are represented by hexagonal boxes. At decision points you must provide us with information about further treatment you intend to provide (Decision Point Review). In addition, the administration of any test on the list in Exhibit B also requires Decision Point Review regardless of the diagnosis. The Care Paths and accompanying rules are available on the Internet on our website at www.chn.com or by calling CHN Solutions at 1-800-293-9795. If you fail to submit requests for decision point reviews or fail to provide clinically supported findings that support the requests, payment of your bills may be subject to a penalty co-pay even if the services are determined to be medically necessary.

MANDATORY PRE-CERTIFICATION

If your patient does not have an Identified Injury, you are required to obtain Pre-Certification of all services itemized in Exhibit B. If you fail to pre-certify such services or fail to submit clinically supported findings that support your pre-certification request, payment of your bills may be subject to a penalty co-pay even if the services are determined to be medically necessary. You are encouraged to maintain communication with CHN Solutions on a regular basis as Pre-Certification requirements may change. For your convenience CHN Solutions posts Pre-Certification requirements on its website at www.chn.com or contact our Provider Relations Department at 1-800-293-9795.

VOLUNTARY PRE-CERTIFICATION

You are encouraged to participate in a Voluntary Precertification process by providing CHN Solutions with a comprehensive treatment plan for both identified and other injuries. CHN Solutions will utilize nationally accepted criteria and the Care Paths to work with you to certify a mutually agreeable course of treatment to include itemized services and a defined treatment period. In consideration for your participation in the Voluntary Pre-Certification process, the bills you submit, when consistent with the plan means that as long as treatment is consistent with the plan, additional notification to CHN Solutions at decision points is not required. As you continue to participate in the Voluntary Pre-Certification process for subsequent services, payment for pre-certified services will be made without utilization audit.

HOW TO SUBMIT DECISION POINT/PRE-CERTIFICATION REQUESTS

In order to complete our review, we require that you provide us with any past medical history that is available. We also require the diagnosis, prognosis, all x-ray and other test results that may have been completed, and documentation of all treatment provided to date. Please indicate any tests or treatment you anticipate over the next 30 days.

CHIROPRACTIC TREATMENT PLANS must include ALL records to date that have not been previously submitted. To avoid delay and the necessity for resubmission, decision point review and pre-certification requests should state that ALL records have been submitted for review.

Enclosed is an Attending Provider Treatment Plan form that you must use. Please return this completed form, along with a copy of the most recent/appropriate progress notes, and results of diagnostic tests or studies relative to the requested services (FAX 1-877-254-9572). When necessary you may telephone the Pre-Certification Department with your request (1-800-293-9795) or e-mail us at chnum@chn.com.

Our review of Decision point/Pre-Certification requests will be completed within 3 business days of receipt of the necessary information. Notice of certification will be made to your office by telephone and confirmed in writing. If we fail to notify you within 3 business days, you may continue with the test or treatment until a final determination is communicated to you. Any decision to deny a request based on medical necessity will be made by a physician or dentist. We will not retrospectively deny payment for treatment, testing or durable medical equipment where the Decision Point Review or Pre-certification request was properly submitted to CHN unless the request involved fraud or misrepresentation by you or the person receiving treatment.

If an independent physical or mental examination is required, medically necessary treatment may proceed while the examination is being scheduled and the results become available. If an examination is requested, the exam will be: scheduled within 7 days of the Decision Point Review or Pre-Certification request, conducted by a health care provider similar in specialty to you; and conducted at a location reasonably convenient to your patient. You will be notified within three business days of the results of the Independent Medical Examination. The Independent Medical Examination report will be available upon request. If your patient has two or more unexcused failures to attend the scheduled Independent Medical Examination, you and the injured person will be notified that expenses for all future treatment, diagnostic tests or durable medical equipment for the diagnosis and related diagnoses included on the Attending Provider Treatment Plan form will not be reimbursable as a consequence for failure to comply with the plan.