New Jersey Administrative Code

Failure of an insurer to comply with these rules may result in the imposition of penalties prescribed by law. Notes N.J. Admin. Code § 11:3-24.6

(a) The purpose of this subchapter is to implement N.J.S.A. 39:6A-5, as amended by P.L. 1995, c.407, by establishing procedures to be followed by treating medical providers to give timely notification of the commencement of medical treatment for injuries sustained in automobile a…

For treatments rendered between January 6, 1997 and July 6, 1997, all eligible charge reductions set forth in N.J.A.C. 11:3-25.5(b) shall be reduced by 50 percent (for example, a 10 percent reduction shall be five percent, a 25 percent reduction shall be 12.5 percent, etc.). Note…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Coverage status" means the status of PIP coverage for an injured party pursuant to N.J.S.A. 39:6A-5. "Department" means the Department …

(a) When medical treatment is rendered for which a claim for payment will be made pursuant to the PIP coverage of a private passenger automobile insurance policy, a treating health care provider shall provide notice to the PIP insurer no later than 21 days following the date of t…

(a) The treating health care provider shall send the written notice required by N.J.A.C. 11:3-25.3(a) to the PIP insurer on either: 1. The "Notification of Commencement of Medical Treatment Form" found in Appendix A, appended to and incorporated by reference in this subchapter; o…

(a) In the event notice of commencement of medical treatment is made after 21 days, the insurer shall advise the treating health care provider in writing of the late notification and may reserve the right to reduce payment in accordance with (b) below. (b) Where notice of the com…

(a) Notwithstanding the reductions set forth in N.J.A.C. 11:3-25.5(b), insurers may choose to pay the full or a less reduced amount of an eligible charge based upon consideration of the following factors: 1. Whether the treating health care provider has previously provided untime…

Whenever an eligible charge has been reduced or denied pursuant to N.J.A.C. 11:3-25.5(b), the treating health care provider shall not seek to obtain payment directly from the insured or the person receiving treatment. Notes N.J. Admin. Code § 11:3-25.7 Amended by R.1998 d.591, ef…

A treating health care provider who fails to notify the insurer within 21 days and whose claim has been reduced or denied by the insurer pursuant to N.J.A.C. 11:3-25.5(b) may, in the discretion of a judge of Superior Court, be permitted to refile such claim provided that the insu…

(a) By February 5, 1997, every insurer shall file with the Department the address, facsimile number (if notice by facsimile is permitted) and E-mail address, if any, of the designated location for the filing of notice required under this subchapter. Insurers shall use Appendix B,…

(a) Notice of intention to make a claim under N.J.S.A. 39:6-65 shall contain the following information:1. The claimant's name, address, date of birth and social security number; 2. The time, date, location, municipality and county in which the loss occurred; 3. The identity of th…

(a) A Notice of Intention to Make Claim under N.J.S.A. 39:6-65 may be filed on the form designated by the Unsatisfied Claim and Judgment Fund identified as a "Notice of Intention to Make Claim", incorporated herein by reference as Appendix A. (b) A written notice to the Board in …

(a) Upon review of a case by the Unsatisfied Claim and Judgment Fund Board's designee, if the designee does not have sufficient current information to determine whether or not the uninsured's installment payment is reasonable, a request will be addressed to the uninsured asking f…

(a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimburseable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $ 10,000 or more subm…

(a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000 and an on-site audit where such claims are equal to or in excess of $50,000. 1. …

(a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used for the benefit of the claimant, the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, including a Van P…

(a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the Fund. (b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in …

(a) The Fund shall reimburse insurers for paid medical expense benefit claims if an insurer demonstrates that it has diligently pursued all potentially responsible tortfeasors within the time prescribed at N.J.S.A. 39:6A-9.1, or any other applicable limitation period.1. An insure…

(a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which: 1. Acknowledges receipt of the assignment and the accompa…

Notes N.J. Admin. Code § 11:3-28.15 Repealed by R.2006 d.243, effective 7/3/2006. See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c). Section was "Procedures for handling as assigned uninsured motorist claim".

§ 11:3-28.16 - Reserved Notes N.J. Admin. Code § 11:3-28.16

Notes N.J. Admin. Code § 11:3-28.17 Repealed by R.2006 d.243, effective 7/3/2006. See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c). "Section was "Penalties".

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Board" means the Board of the New Jersey Property-Liability Insurance Guaranty Association created in accordance with N.J.S.A. 17:30A-1…

In cases where the potential exposure to the automobile liability insurer exceeds $ 75,000, the insurer shall report on UCJF Form 1(321) (incorporated herein by reference as Form 1 in Appendix A) whenever medical expense benefits in a total amount of $ 50,000 have been paid on ac…

Whenever an automobile liability insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount of $ 50,000, said insurer shall notify the Fund of any changes in the amount of reserves established for payment of the…

(a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount in exces…

(a) An automobile liability insurer shall be required to discharge its duty of investigating claims where the potential exposure to the insurer exceeds $75,000. Said insurer's duty and obligation with regard to claim handling shall exist and continue to exist notwithstanding this…

(a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim payments of $ 20,000 or more. For claim payment…

Upon request of the Fund, the insurer(s) shall present for audit at the direction of the Executive Director at a New Jersey location all policy and claim records on which notice of potential for payment of excess medical expense benefits have been submitted. Notes N.J. Admin. Cod…

(a) For purposes of completing page 14, Exhibit of Premiums and Losses, of the annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall include the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments …

(a) Every policy of automobile insurance and motor bus insurance issued in this State shall provide that the automobile insurer's limit of liability for medically necessary expenses payable under PIP coverage, and the motor bus insurer's limit of liability for medically necessary…

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

(a) The Regions in Appendix, Exhibit 1, Physicians' Fee Schedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, are as follows: 1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counti…

(a) Nothing in this subchapter shall compel the PIP insurer or a motor bus insurer to pay more for any service or equipment than the usual, customary and reasonable fee, even if such fee is well below the automobile insurer's or motor bus insurer's limit of liability as set forth…

(a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hosp…

No health care provider may demand or request any payment from any person in excess of those permitted by the medical fee schedules and this subchapter, nor shall any person be liable to any health care provider for any amount of money that results from the charging of fees in ex…

(a) The purpose of this subchapter is to assist certain low income individuals in this State and encourage their greater compliance in satisfying the mandatory private passenger automobile insurance requirements imposed by N.J.S.A. 39:6A-3.2. (b) This subchapter shall apply to al…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance. "Department" means the New Jersey Department …

(a) The special automobile insurance policy shall be administered by the PAIP in accordance with a Special Policy plan of operation prepared by PAIP and approved by the Commissioner. The plan of operation shall include: 1. The procedure for the writing of Special Insurance Polici…

(a) The special automobile insurance policy shall only be available to individuals who are eligible for and enrolled in the Federal Medicaid program pursuant to N.J.S.A. 30:4D-3i(1) through (14). (b) The PAIP special automobile insurance policy plan of operation shall provide pro…

(a) The following coverages shall be included in all special automobile insurance policies: 1. Emergency personal injury protection coverage for emergency care not to exceed $ 250,000 per person per accident; and 2. A death benefit in the amount of $ 10,000. (b) The limitation on…

No insurer shall issue a special automobile insurance policy unless the named insured has signed a document entitled Special Policy Coverage Selection Form approved by the Commissioner. Notes N.J. Admin. Code § 11:3-2A.6

(a) This subchapter provides rules to be utilized by insurers in developing the policy forms and rates for basic automobile insurance policies to be filed with and approved by the Department in accordance with the provisions of N.J.S.A. 39:6A-3.1. (b) This subchapter shall apply …

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise: "Basic automobile insurance policy" or "basic policy" means that automobile insurance policy offered pursuant to N.J.S.A. 39:6A-3.1 and t…

(a) All insurers writing private passenger automobile insurance and the Personal Automobile Insurance Plan shall file for approval with the Department their rates, rules and policy forms for a basic automobile insurance policy to be issued in accordance with N.J.S.A. 39:6A-3.1 an…

(a) The following coverages shall be included in all basic policies: 1. Personal injury protection medical expense benefits coverage in an amount not to exceed $ 15,000 per person, per accident; except that all medically necessary treatment of permanent or significant brain injur…