STATE OF NEW JERSEY

DEPARTMENT OF BANKING AND INSURANCE


IN THE MATTER OF THE )

PERSONAL INJURY PROTECTION ) ORDER

TECHNICAL ADVISORY COMMITTEE )

 

This matter having been opened by the Commissioner of the Department of Banking and Insurance ("Commissioner") pursuant to the authority of N.J.S.A. 17:1-15i; and

IT APPEARING that the Automobile Insurance Cost Reduction Act, P.L. 1998, c. 21 as amended by P.L. 1998, c. 22 ("the Act") was enacted May 19, 1998; and

IT FURTHER APPEARING that as required by the Act, the Commissioner, in consultation with the professional licensing boards in the Division of Consumer Affairs of the Department of Law and Public Safety ("Professional Boards") and the Commissioner of the Department of Health and Senior Services ("DOH&SS"), has adopted administrative rules at N.J.A.C. 11:3-4 ("rules") that more precisely define the benefits available under automobile insurance personal injury protection ("PIP") coverage and establish standard treatment and diagnostic procedures for treatment of accidental injury to the spine and back against which the medical necessity of treatments reimbursable under PIP medical expense benefits coverage can be judged; and

IT FURTHER APPEARING that as part of its consultation with the Department of Banking and Insurance ("Department"), the Director of the Division of Consumer Affairs in the Department of Law and Public Safety formed an ad-hoc committee composed of representatives of those Professional Boards most directly impacted by the reforms to PIP and this ad-hoc committee worked efficiently in accomplishing the goals of the Act; and

IT FURTHER APPEARING that during and after the rule proposal process there was a high level of interest and concern from medical professionals, members of the legislature and the general public that insurers would implement the rules in an arbitrary manner to deny reimbursement for medically necessary care; and

IT FURTHER APPEARING that the treatment standards established by the Departmentís rules are not meant to be applied rigidly or in such a manner as to deny reimbursement for medically necessary care; and

IT FURTHER APPEARING that especially during the implementation process, the Commissioner has determined to continue consultation not only with the Professional Boards and the DOH&SS, but also with other knowledgeable interested parties about the rules and to establish formally an appropriate mechanism for that continuing consultation; and

IT FURTHER APPEARING that pursuant to N.J.S.A. 17:1-15i, the Commissioner may appoint an advisory committee to advise and assist her in carrying out the functions and duties of the Department of Banking and Insurance; and

THEREFORE, IT IS on this 10th day of March, 1999 ORDERED that:

    1. The Personal Injury Protection Technical Advisory Committee ("PIPTAC") is created and will be convened by the Commissioner to assist her in:

    1. Determining whether the standards for treatment established in the adopted rules result in injured persons receiving necessary medical care, and, if necessary, recommending changes to those standards;
    2. Determining whether reimbursement for medically necessary care of injuries sustained in automobile accidents is being inappropriately or arbitrarily denied by insurers by reviewing data collected on implementation and relevant non-confidential complaint information;
    3. Preparing a report on the implementation of the rules to be made to the Legislature after a review of data collected during the first 18 months of implementation of the rules after the effective date of the Act. The report shall set forth issues raised during the implementation process that resulted in recommendations for changes to the rules and/or statute.

    1. The initial membership of the committee shall be as follows:

    1. Representatives of appropriate Professional Boards designated by the Director of the Division of Consumer Affairs in the Department of Law and Public Safety
    2. The Commissioner of the Department of Health and Senior Services;
    3. The Insurance Fraud Prosecutor;

iv. Four representatives designated by the Commissioner upon nomination by professional organizations whose members are involved in the insurance process;

v. Four representatives of the insurance industry; and

vi. Two representatives of the public who are not health care providers, nor employed by, or affiliated with, any insurer, health care provider, nor shall they be any person, or any person who is employed by or is affiliated with any person who has received remuneration from an insurer or has a financial or any other interest in the automobile insurance system other than as a policyholder.

3. The Commissioner may designate additional members of the committee or replace existing members without need of further formal order.

4. The committee shall assist the Commissioner in evaluating the implementation of the rules by reviewing data regularly provided to it by the Commissioner including:

i. The number of requests for decision point review and the number of such requests denied as medically unnecessary;

ii. The number of medical reviews scheduled;

iii. The number of comprehensive treatment plans submitted and the number approved or disapproved;

iv. The number of requests for review by Medical Review Organizations that are made pursuant to N.J.A.C. 11:3-5.6 by the Alternate Dispute Resolution Administrator; and

v. The final determinations of dispute resolution professionals filed with the Department pursuant to N.J.A.C. 11:3-5.7(b).

5. Based on its review of the data provided by the Commissioner, the committee may recommend to the Commissioner that the Department:

i. Undertake examinations or claims audits of certain insurers;

ii. Request that the conduct of certain providers be reviewed by the appropriate Professional Board in the Division of Consumer Affairs in the Department of Law and Public Safety;

iii. Make amendments to the currently approved rules or recommend changes to statutes.

6. Upon designation of the committee, the Commissioner shall establish the date and time of the first meeting, which shall be no longer than 60 days from the date of this Order and thereafter the Committee shall meet as often as may be directed by the Commissioner, but at least once every two months.

/s/ Jaynee LaVecchia

Commissioner



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