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Implementation of Internal Appeal Rule: Frequently Asked Questions - operative April 17, 2016
Updated: May 4, 2017

Disclaimer: This document is a compilation of the most frequently asked questions (FAQ) concerning the implementation of the Requirements for Internal Appeal Procedures of the Personal Injury Protection ("PIP") Medical Protocols Rule, which is published in the New Jersey Register at N.J.A.C. 11:3-4.7B. The purpose of this document is to respond to questions of general application raised by providers and payers. Information in this FAQ is not intended to replace the provisions of the rule, which govern. The information in this FAQ may be updated, corrected or deleted at any time without notice.

Please note that the Department does not interpret its rules in response to questions. Neither does it perform legal research, provide legal advice or issue advisory opinions to members of the public or other entities. The Department believes that the text of the statutes and rules, the responses to comments on adoption and the Bulletins and Orders issued by the Department, all of which are on our website (www.state.nj.us/dobi/pipinfo/aicrapg.htm), contain the necessary information.

 
General Questions

Q: How will the April 17, 2017 operative date of the new internal appeals rule be implemented?

A: The Department believes that the rule should apply to new pre-service and post-service appeals that are submitted on or after April 17, 2017.  Appeals that are already in progress, including second level appeals, would continue under the insurer's old system. This would result in all appeals being handled consistently in accordance with the regulation from 04/17/2017 going forward.  This will be less confusing for providers and insurers and is consistent with how the effective date of other changes to DPR plans have been handled by the Department.

Q: The Internal Appeal Procedures rules does not state how the appeal forms are to be transmitted to the insurer by the appealing party. There is no space on the form to indicate if the form should be submitted to the insurer or the insurer’s PIP vendor.

A: The information on where and how the internal appeal forms shall be transmitted to the insurer will be contained in the insurer’s Decision Point Review plan.

Q: If the provider fails to complete the form in its entirety, can the insurer deny the appeal request administratively?

A: The insurer’s requirement concerning administrative denials should be contained in the insurer’s Decision Point Review plan.

Q: Can either party in an arbitration submit additional documentation at the arbitration that was available but not included as part of the internal appeal?

A: N.J.A.C. 11:3-4.7B(d) requires providers to submit the appeal forms and any supporting documentation to the insurer pursuant to its Decision Point Review Plan.  The Department interprets this provision as requiring the provider to submit all supporting documentation for a requested treatment or reimbursement to the insurer that is available at the time of the internal appeal.  Based upon this information, the insurer will make a determination on the internal appeal and shall issue a decision that fully states the basis for the decision, including referencing any supporting documentation in the insurer’s possession that is the basis for the decision.  There is no requirement for the insurer to produce or attach the documentation referenced in the decision.
The Department believes that the internal appeal process is the primary venue where the issue being appealed by the provider should be addressed fully.  Although there is no specific provision for it in the rule, at arbitration, both parties can object to additional documentation and information being produced that was available at the time of the internal appeal but not submitted. The Dispute Resolution Professional should specifically address whether such documentation or information should be considered in his or her decision.  The Dispute Resolution Professional’s determination in this matter should be made in accordance with the existing No-Fault Arbitration Rules.

Q: Many providers just write the word “appeal” over the original denial with no explanation to support the appeal. Many providers send the same exact information for appeals that they sent for the original request that was already reviewed. Shouldn’t the provider be required to provide additional information to support the appeal in addition to the appeal form?

A: The appeal forms should address these issues. The form makes it easy for the provider to indicate exactly what issues are being appealed. Further, an appeal rationale narrative is required to be included with the form.

Q: Insurer X’s internal appeal plan has provisions that are not in the rule. I thought we were getting a uniform internal appeal process.

A: The Department stated in its responses to comments on the proposal of the rules that it would permit insurers to include other provisions in their internal appeal procedure that do not conflict with the requirements of the rule. By mandating a uniform appeal form and general structure of appeals, the Department believes that it has made the process much more user friendly and efficient.

 
Appeal Form Questions

BOTH FORMS:


Q: Is the PIP Post-Service Appeal Form required to be used for all PIP claims?

A: No, the PIP Post-Service Appeal Form is to be used for an appeal subsequent to the performance or issuance of the services and/or what should be reimbursed as required by the Department’s Protocols rule, N.J.A.C. 11:3-4.7B and individual insurer Decision Point Review Plans. It replaces the forms used by individual insurers.

Q: There are two links to the Form on the Department’s web site. What is the difference?

A: The Department has provided the form on its web site as a PDF, which is the type of file used with the Adobe Acrobat program, and can be downloaded for free. Acrobat files are images and therefore retain the exact format of the document as it was created and are often used with forms. The form was created in Microsoft Excel and is also available in this file format (.xlsx).

Q: If a Provider/Facility completes sections 27-28 showing when they would be available for a telephonic discussion does this guarantee a discussion will take place and it will occur within the time provided?

A: No, the need for a telephonic discussion will be determined by the reviewer and if the need arises for a telephonic discussion, the best time to contact will be consulted to expedite the review. The Department would encourage the requesting provider/facility to reference the insurers DPRP for days and hours of operation.

Q: When supplying documents indicated in section 29, should the Provider/Facility include a copy of the original associated/supporting records?

A: No, when supplying the documents indicated in section 29, the Provider/Facility would only need to supply associated/supporting records if they are new/in addition to the original associated/supporting records supplied.

Q: The Appeal Form on the Department’s web site is in red type. Is red type mandatory?

A: No, the red type is used in some scanning applications. Insurers and providers can complete the form in black or red ink.

Q: The appeal forms must be signed by the provider. However, where a surgical center is the provider, is the signature of the head of billing sufficient since it is a surgical facility? The individual physicians do not have offices at the surgical center.

A: N.J.A.C. 11:3-4.2 defines “provider” as including hospitals and health care facilities licensed or certified to provide health care treatment or services reimbursable under PIP. This would include ASCs. In the case of an ASC or other facility, the person signing the appeal form should be the responsible party at the facility who is able to make the certification required on the bottom of the form that the information is true & correct, etc.

Q: Is it acceptable to type in the doctor name indicating it was electronically signed?

A: An electronic signature on the appeal form is acceptable. However, regardless of how the form is signed, the person signing the form is making the certification required on the appeal forms.


PRE-SERVICE APPEAL QUESTIONS:

Q:
Can a Provider/Facility use a single form to submit appeals from multiple APTP documents?

A: No, the form design is intended to be used for an individual APTP.

Q: If a Provider/Facility cannot fit all the services in the lines provided on the Pre-Services Appeals Issues (sections 30-34), what do they do?

A: The requesting provider/facility can use an additional form and complete only the Pre-Services Appeals Issues (sections 30-34) on the second form. Use the “Documents Included” (section 29) on the original form and choose “other supporting documents box” to indicate a second page is attached and was required to complete the submission.

To reduce the need for a second form, providers should only include the CPT, HCPCS or NDC request denials that they are appealing.

Q: Can a Provider/Facility submit more than one pre-service appeal form (and supporting documentation) at the same time?

A: Yes, but to limit confusion and mistakes, each pre-service appeal form should be followed by the associated documentation indicated in section 29. The Department does not recommend putting several pre-service appeals forms together followed by all the associated documentation.

Q: What does section 32, “Response not received within 3-business days” mean? I thought that if the insurer doesn’t respond to a DPR or precert request within 3 business days, the treatment or test is approved?

A: Some providers submit APTP forms when they have not received a response as appeals. The box allows this to be indicated.


POST-SERVICE APPEAL QUESTIONS:

Q:
If a Provider/Facility cannot fit all the services in the lines provided on the Post-Services Appeals Issues (sections 34-38), what do they do?

A: The requesting provider/facility can use an additional form and complete only the Post-Services Appeals Issues (sections 34-38) on the second form. Use the “Documents Included” (section 29) on the original form and choose “other supporting documents box” to indicate a second page is attached and was required to complete the submission.

To reduce the need for a second form, the Department recommends the requesting provider/facility providers should only include the lines on the bill that they are appealing.

Q: What is the best way to indicate the use of more than one code in sections 33 & 38?

A: The Department would recommend the following:

If the codes are in a range with no skip in between use a dash (-), if there is a skip in a range or between ranges use a comma (,).

Examples: A, B, C, D, F, I, J & K would be displayed as A-D, F, I-K

Q: Can a Provider/Facility submit more than one post-service appeal form (and supporting documentation) at the same time?

A: Yes, but to limit confusion/mistakes, each post-service appeal form should be followed by the associated documentation indicated in section 29. The Department does not recommend putting several post-service appeals forms together followed by all the associated documentation.

Q: Can a Provider/Facility use a single form to submit appeals from multiple EOB documents received?

A: No, the form design is intended to be used for an individual EOB.

Q: Can you provide clarification on when to use the NJ PIP Post-Service Appeal Reason Code “K” – Improper Application of Retrospective Medical Necessity Denial?

A: If treatment is rendered and billed without the submission of a Attending Provider Treatment Plan form (for services within the 1st 10 days of the accident or for services associated to diagnoses within a care path prior to the 1st decision point review) and the treatment is denied for medical necessity retrospectively the use of Post-Service Appeal Reason Code “K” would be appropriate to appeal the medical necessity denial decision.

Q: Can you provide clarification on when to use the NJ PIP Post-Service Appeal Reason Code “L” – Improper Application of Bill Audit Reduction?

A: Bill Audit refers to a professional review (usually performed by an audit nurse) of areas to include but not limited to: billing documentation, length of stay, and necessity for admissions. These types of reviews apply similar guidelines to those related to bills that pierce thresholds associated to UCJF/PLIGA guidelines. This type of appeal should not be used as a catch all for general bill reductions. This applies primarily to hospital bills.

Q: Would a narrative still be required for a post-service appeal if the service was authorized since there is no medical necessity issue? Would the provider simply note that the procedure was approved and then list the reasons for the appeal vs what was paid?

A: The narrative is where the provider explains the basis for the appeal. In the case of a post-service appeal, it is not necessary to reference medical necessity if that is not an issue. However, the narrative should give the relevant details that support the reason code provided on the form. So, for example, if the Bill Level Code for the appeal is #4: Interest Due – Payment Not Made Timely, the narrative would state that the service was billed on X date and the payment was made on Y date, which is outside the prompt payment deadlines of N.J.S.A. 39:6A-5g.

If the Line Level Appeal Code was #F, Improper Application of U&C Amount, the narrative would explain why the U&C amount paid is not correct and reference the documentation provided of the correct U&C amount.

Q: Both box 33 and 38 (Bill-Level and Line-Level Appeal Codes) have double asterisks (**), which means that they should be completed using the letter(s) or number(s) on the reverse of the form. Does this mean that on a Post-Service Appeal codes need to be put in both boxes?

A: No, the basis of the appeal should be either a bill-level or a line-level issue. The provider should use the appropriate box and codes for the issue being appealed.

 
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