New Jersey Administrative Code

(a) When, subsequent to the selection of the PIP-as-secondary coverage option by a named insured, it is determined that an insured did not have health coverage in effect at the time of an injury, or had health coverage in effect at the time of any injury which is such that the PI…

(a) When no election has been made by a named insured to make his or her health benefits plan(s) primary coverage provider(s), so that the PIP plan will provide primary coverage for medical expenses incurred for treatment of injuries, the PIP plan shall provide benefits to the in…

The purpose of this subchapter is to encourage consumers to invest in and use anti-theft and vehicle recovery devices and safety features in private passenger automobiles by providing that there shall be a reduction in the base rates applicable to automobile physical damage cover…

(a) This subchapter shall apply to all insurers which write private passenger automobile insurance in this State. (b) This subchapter shall apply to all policies which include provisions for physical damage coverage and which are issued or renewed on or after September 1, 1991. N…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Alarm" means a device which emits sounds audible at 300 feet or more, such as a horn, bell or siren, but does not include those sounds …

(a) Every insurer writing automobile physical damage insurance shall provide a reduction in the base rates of its comprehensive and fire and theft coverages, if different, for all private passenger automobiles equipped with one or more anti-theft or vehicle recovery devices, as d…

(a) A device qualifies as a Category I anti-theft device if it meets the requirements of one of the devices listed below. 1. An ignition or starter cut-off switch device is qualified if a warning label announces the presence of the device, and the device is designed so that the c…

(a) Except as (d) below may apply, every insurer writing automobile physical damage insurance shall provide a reduction in the base rates of its collision damage coverage for all private passenger automobiles equipped with one or more safety features. Reductions in the base rates…

Any insurer which fails to comply with the terms of this subchapter shall be in violation of this subchapter, and subject to the assessment of any and all penalties in accordance with the laws of this State. Notes N.J. Admin. Code § 11:3-39.7

If any provision of this subchapter or application thereof to any person or circumstances is held invalid, the remainder of the subchapter and application of such provisions to other persons or circumstances shall not be affected thereby. Notes N.J. Admin. Code § 11:3-39.8

(a) This subchapter implements the provisions of N.J.S.A. 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injury protection medical expense benefits and emergency personal injury protection coverage for which reimbursement of eligible charges will be made by automobi…

Notes N.J. Admin. Code § 11:3-4.10 New Rule, R.2000 d.454, effective 11/6/2000. See: 31 New Jersey Register 4210(a), 32 New Jersey Register 4005(c). Amended by R.2003 d.3, effective 1/6/2003. See: 34 New Jersey Register 2518(a), 35 New Jersey Register 249(b). Rewrote (a) and (b).…

The following words, phrases, and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Ambulatory surgery facility" or "ambulatory surgical center" (ASC) means: 1. A surgical facility, licensed as an ambulatory s…

(a) Personal injury protection coverage shall provide reimbursement for all medically necessary expenses for the diagnosis and treatment of injuries sustained from a covered automobile accident up to the limits set forth in the policy and in accordance with this subchapter. (b) P…

(a) Each insurer shall offer a standard $ 250.00 deductible and 20 percent copayment on medical expense benefits payable between $ 250.00 and $ 5,000. (b) Each insurer shall also offer, at appropriately reduced premiums, the option to select medical expense benefit deductibles of…

(a) The personal injury protection medical expense benefits coverage shall not provide reimbursement for the following diagnostic tests, which have been determined to yield no data of any significant value in the development, evaluation and implementation of an appropriate plan o…

(a) Pursuant to N.J.S.A. 39:6A-3.1 and 39:6A-4, the Commissioner designates the care paths, set forth in the subchapter Appendix incorporated herein by reference, as the standard course of medically necessary treatment, including diagnostic tests, for the identified injuries. (b)…

(a) No insurer shall impose the co-payments permitted in N.J.A.C. 11:3-4.4(e), (f) and (g) unless it has an approved decision point review plan. 1. Initial decision point review plan filings and amendments to approved plans shall be submitted to the Department through the use of …

(a) No company shall perform utilization management services for an insurer unless registered as a PIP vendor pursuant to this section. (b) Any PIP vendor working for an insurer prior to November 5, 2012 shall file for registration by February 3, 2013. (c) Application for registr…

(a) The internal appeal procedure in an insurer's Decision Point Review Plan (DPR Plan) shall meet the requirements in this section. (b) Insurers shall only require a one-level appeal procedure for each appealed issue before making a request for alternate dispute resolution in ac…

(a) No insurer shall file a decision point review plan utilizing a voluntary network or networks unless the network is a health maintenance organization licensed pursuant to N.J.S.A. 26:2J-1 et seq.; or approved by the Department as part of a selective contracting arrangement wit…

(a) Pursuant to N.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policy to a provider of service benefits. Insurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of personal injury protection ben…

(a) The purpose of this subchapter is to:1. Provide for the establishment of a private passenger automobile insurance urban enterprise zone program pursuant to N.J.S.A. 17:33C-1 et seq., and for the voluntary rating tier of the PAIP pursuant to N.J.S.A. 17:29D-1i; and 2. Encourag…

(a) Qualified producers shall receive commissions for risks placed in the voluntary rating tier from the insurer to which the risks are distributed. Such commissions shall be equivalent to the insurer's usual commission rate for its agents or brokers, or may be a newly establishe…

(a) A producer requesting coverage through the voluntary rating tier on behalf of an applicant shall file with the PAIP an application for coverage in a form acceptable to the Commissioner. The application shall contain the information required to constitute a completed written a…

(a) The PAIP shall develop any amendments or supplements to the PAIP Plan of Operation as may be necessary or appropriate to provide for the implementation of N.J.A.C. 11:3-46.6, 46.7, 46.8, 46.9, 46.10, and 46.11. Such amendments or supplements shall be subject to review and app…

(a) Each automobile insurer shall report on a quarterly basis its in-force private passenger automobile exposures in UEZs by zip code for the periods ending March 31, June 30, September 30, and December 31. Such reports shall be filed within 10 days of the end of each quarter and…

Failure to comply with this subchapter shall result in the imposition of penalties as authorized by law, including, but not limited to, a penalty up to $ 1,000 for a first violation, and up to $ 2,000 for each subsequent violation, pursuant to N.J.S.A. 17:33-2; and a fine up to $…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Automobile" means an automobile as defined pursuant to N.J.S.A. 39:6A-2. "Automobile insurance" means personal lines private passenger …

(a) Pursuant to N.J.S.A. 17:33C-2, the Commissioner has identified and designated as UEZs certain urban-based geographic areas where the Commissioner has found that automobile insurance consumers would benefit from increased access to automobile insurance as set forth below. UEZs…

(a) An automobile insurer may apply to the Commissioner to be considered a qualified insurer for purposes of participating in the UEZ program. An automobile insurer seeking to become a qualified insurer shall demonstrate that it will actively conduct business in UEZ areas by fili…

(a) A qualified insurer may appoint one or more UEZ agents on or after January 1, 1998. Such appointments shall comply with all requirements set forth in N.J.S.A. 17:33C-4 and 17:22A-15, N.J.A.C. 11:17-2.9, and this subchapter. UEZ agent contracts shall set forth any limitation o…

(a) Pursuant to N.J.S.A. 17:29D-1i, the PAIP Plan of Operation shall provide for the establishment of a voluntary rating tier in which persons residing in UEZs may be written by certain UEZ agents and qualified producers, as set forth in N.J.A.C. 11:3-46.7. The rates utilized in …

(a) Only UEZ agents who have met any limit on exposures that may be written in accordance with the UEZ agent's agreement with the appointing insurer pursuant to N.J.S.A. 17:33C-4, and who is certified by the PAIP, or qualified producers as set forth below, shall be permitted to s…

(a) In determining whether a producer has demonstrated competency, efficiency and effectiveness in the solicitation, negotiation and effectuation of insurance, the PAIP's review shall include, but need not be limited to, the following: 1. Any records concerning the termination of…

(a) A producer's application to be a qualified producer under the voluntary rating tier shall be disapproved if, based on the PAIP's review as set forth in N.J.A.C. 11:3-46.8: 1. The producer failed to file a completed application with the PAIP as provided in N.J.A.C. 11:3-46.7(c…

(a) The purpose of this subchapter is to establish procedures for the resolution of disputes concerning the payment of medical expense and other benefits provided by the personal injury protection coverage in policies of automobile insurance. This subchapter implements N.J.S.A. 3…

(a) The Commissioner shall certify a medical review organization to provide medical review services in connection with the resolutions of PIP disputes if the Commissioner determines that the MRO complies with the standards set forth in N.J.A.C. 11:3-5.9 to provide an impartial re…

When a mental or physical examination is performed in connection with the medical review organization's services, the health care provider performing the examination shall be paid the fee provided for that service set forth on the Department's medical fee schedule, N.J.A.C. 11:3-…

(a) No administrator or employee thereof, dispute resolution professional, medical review organization or reviewing health care provider shall have any personal or financial interest, direct or indirect, or engage in any business or transaction which is in conflict with the prope…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Administrator" means the dispute resolution organization designated by the Commissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:…

(a) The Commissioner shall designate a dispute resolution organization as the administrator of the PIP alternate dispute resolution system by entering into a contract with a dispute resolution organization. (b) The contract designating the administrator shall be for a term not to…

(a) In order to be eligible for designation as administrator, a dispute resolution organization shall meet the following criteria: 1. The dispute resolution organization shall not be owned or controlled by an insurer or affiliate of an insurer; 2. The dispute resolution organizat…

(a) A dispute resolution professional employed by the dispute resolution organization shall be either: 1. An attorney licensed to practice in New Jersey with at least 10 years of experience in cases involving personal injury or workers' compensation; 2. A former judge of the Supe…

(a) A request for dispute resolution of a PIP dispute may be made by the injured party, the insured, a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or the insurer, in accordance with the terms of the policy as approved by the Commissioner. The request…

(a) The administrator shall maintain records of all determinations for a period of five years. (b) The administrator shall file a copy of each determination, except consent determinations, with the Department in either hard copy or electronic form, as provided in the contract des…

(a) Medical review organizations shall be authorized to determine in connection with the PIP dispute resolution process set forth in this subchapter: 1. Whether the medical treatment or diagnostic test is medically necessary; 2. Whether the treatment is in accordance with medical…

(a) Medical review organizations shall be capable of performing medical reviews for all primary specialties and disciplines. (b) Medical review organizations shall employ a medical director to actively participate in the review of cases to assure quality and consistency. (c) Medi…

In accordance with N.J.S.A. 39:3-29.1, this subchapter concerns the issuance, design, and content of insurance identification cards for motor vehicles issued by insurers in this State. This subchapter shall not apply to policies covering motor vehicles registered with the U.S. De…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Electronic insurance identification card or E-card" means the display of an electronic image on a cellular phone or any other type of p…