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Home > Insurance Division > PIP Information for Health Care Providers > FAQS About the Medical Protocols Rule
Frequently Asked Questions About the Medical Protocols Rule
General Questions

Q: What is the relationship between a physical examination required by N.J.A.C. 11:3-4.7(d)5 and (e) as part of an insurer's Decision Point Review Plan and one required by N.J.S.A. 39:6A-13(d) and (e)?

A: The two types of physical examination are not related and, in fact, have different requirements. Physical examinations performed as part of a Decision Point Review or Precertification request are governed by the requirements in N.J.A.C. 11:3-4.7(e). Physical examinations conducted pursuant to N.J.S.A. 39:6A-13(d) are typically done to demonstrate maximum medical improvement or other claim activity not related to a Decision Point Review or Precertification Request. To avoid confusion, insurers, when requesting a physical examination, should specify the authority under which the examination is being requested.

ICD-10 and PIP Questions

Q: Are services billed under the Personal Injury Protection (PIP) Medical Expense benefit coverage subject to the requirement that only ICD-10 diagnosis codes be used after October 1, 2015?

A: No. The conversion to ICD-10 codes is mandatory for all providers and payors subject to the Health Insurance Portability Accountability Act (HIPAA). Personal Injury Protection (PIP) Medical Expense benefit claims made under auto insurance policies are not subject to HIPAA. However, employer health plans, Medicare and Medicaid are subject to HIPAA and they comprise the vast majority of medical services in the United States. The Department expects that providers, automobile insurers and PIP vendors have already started the process to transition to ICD-10.

Q: Can automobile insurers or PIP vendors require that providers submit an Attending Provider Treatment Plan (APTP) form with diagnoses using ICD-10 codes for dates of service after October 1, 2015?

A: No. Automobile insurers, PIP vendors and providers should be transitioning to ICD-10 codes but at this time, there is no requirement that automobile insurers and PIP vendors accept only ICD-10 codes. The Department may institute such a requirement in the future.

Q: As of October 1, 2015, can automobile insurers refuse to accept an APTP form that contains an ICD-10 diagnosis code?

A: No. Insurers should be prepared to accept APTP’s with ICD-10 codes on October 1, 2015.

Q: I see that the Department has updated the APTP form to include boxes for ICD-10 codes. Should I start using this form immediately?

A: Yes, providers should start using the new form immediately. The earlier form will not be accepted by insurers after April 15, 2016.

Q: Can a provider submit an APTP with ICD-9 codes and a bill with ICD-10 codes for the same services or vice versa?

A: Providers are strongly urged not to mix ICD-9 and ICD-10 codes for an APTP and the billing for those services. This can cause considerable administrative delays/denials in the processing of payments.

Q: Does this FAQ apply to utilization review requests or bill submissions to an insured’s health payor where the insured has selected health insurance primary pursuant to N.J.S.A. 39:6A-4.3(d)?

A: No. Utilization review and bills submitted to a health payor where an insured has chosen the Health Insurance Primary option for PIP must be submitted in accordance with the rules of the Health Payor.

Q: Addendum, Exhibit 9 of the Protocols Rule, N.J.A.C. 11:3-4, has a list of ICD-9 codes that are “associated” with Care Paths 1 through 6. What is the status of these codes?

A: The rule does not require that only these codes be used for Care Path injuries or state that they are an exclusive list. The list of codes was intended to assist providers in determining which types of injuries were subject to the Care Paths when the rules were first adopted in 1999. The rule states that “identified injuries,” which are soft tissue injuries (strain, sprain, contusion, whiplash & disc herniations) to the cervical, thoracic and lumbar/sacral spine, are subject to the Care Paths.

PIP Vendor Questions

Q: How should insurers that use a vendor to administer their Decision Point Review Plans make their filings?

A: In order to make Department review of Decision Point Review Plans as efficient as possible, the Department will accept generic Decision Point Review Plan filings from vendors using the following procedure:

  1. Vendors should file a generic Decision Point Review Plan with the Department for approval.
  2. Once the vendor’s Plan is approved, the vendor’s insurer clients should make a filing with the Department of those plan documents that differ from those of the vendor as well as all Insured/Claimant and provider letters. The filing must show the changes from the vendor’s approved plan by bracketing and underlining. The filing must also include a certification from the insurer that, except as specifically indicated, there are no other changes from the vendor’s filing.

Q: Can Decision Point Review Plans be filed electronically?

A: Insurers and vendors can use the System for Electronic Rate and Form Filing (SERFF) to make plan filings electronically. Information about filing through SERFF is available here or call Jane Borcherding at 816-783-8475 . The Department will not accept filings by e-mail.   System for Electronic Rate and Form Filing (SERFF)

Q: Will the procedures in a new Decision Point Review Plan apply to claims that were opened under the old Decision Point Review Plan?

A: Insurers should include in their Decision Point Review Plans a transition plan that explains how the insurer will provide notice to its existing claimants about the provisions of its new or amended Decision Point Review plan. The transition can be phased in over time for a period not to exceed 3 months.

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