New Jersey PIP
Located in the heart of northern New Jersey, The Law Office of Jeffrey S. Kimmel is a full service New Jersey PIP / No Fault Collections law firm with a streamlined process for filing for arbitration and recovering unpaid PIP / No Fault benefits for doctors, physical and occupational rehabilitation therapists, chiropractors, surgeons, surgical facilities, radiologists, orthopedists, medical supplies companies and countless other healthcare providers throughout New Jersey. We are prepared to get started on your case right away.
What We Need to Get Started
- Assignment of Benefits
- Bills for every treatment/service we are arbitrating
- All Precertification submissions and responses (if applicable) with proof of fax/mailing
- All Internal Appeals submissions and responses (if applicable) with proof of fax/mailing
- All Denials associated with the bills
- All Medical Records
- Notes
- Reports
- Test results
- Hospital records
- And any other relevant records
- An Arbitration summary (tell us which specific bills/services are disputed so we can prepare the Application for Arbitration accordingly)
All documents can be submitted by e-mail, fax, or regular mail.
Unlike other firms, The Law Office of Jeffrey S. Kimmel gives substantial focus to this area of law, and this means we guarantee our no-fault collection clients PERSONALIZED ATTENTION and SPEEDY RESULTS. When you call you will speak directly to Jeffrey S. Kimmel.
New Jersey Personal Injury Protection (PIP) / “No Fault” Overview
New Jersey’s Personal Injury Protection (PIP) / “No Fault” law (N.J.S.A. 39:6A) forces insurance carriers to make prompt payments of benefits for medical expenses incurred by individuals injured in motor vehicle accidents within the state, regardless of who was at fault. All New Jersey auto insurance policies provide mandatory minimum coverage of $15,000 for medical treatment costs. Doctors and other treatment providers in New Jersey whose patients execute an “Assignment of Benefits” can submit their bills for treatment directly to the PIP / No Fault Carrier using standard claim forms. The recovery process, from bill submission requirements to dispute resolution, is outlined below.
Submitting Bills to the PIP / No Fault Carrier
When treating a patient who was injured in a car accident in New Jersey, treatment providers must notify the PIP / No Fault carrier of “commencement of treatment” within 21 days of the first office visit. If the provider gives late notice, the carrier can reduce the amount payable by 10%. The carrier does not have to pay the claim if notice is not received within 161 days. When notice is timely, the carrier must pay each subsequent claim within 60 days of receipt, although the carrier has the right to request a 45-day extension. If a bill is not paid within that time frame, the carrier can be forced to pay interest on the amount billed.
Services Eligible for PIP / No Fault Coverage
The New Jersey PIP / No Fault law defines eligible “medical expenses” as “reasonable and necessary expenses for treatment or services including medical, surgical, rehabilitative and diagnostic services and hospital expenses, provided by a health care provider, licensed or certified by the state or by another state or nation, and reasonable and necessary expenses for ambulance services or other transportation, medication and other services as may be provided for…” N.J.S.A. 39:6A-2(e). Treatment is medically necessary if it is “consistent with the symptoms or diagnosis, and treatment of the injury is not primarily for the convenience of the injured person or provider and is the most appropriate standard or level of service which is in accordance with standards of good practice and standard professional treatment protocols, and does not involve unnecessary diagnostic testing.” N.J.S.A. 39:6A-2(n).
Fee Schedule for Medical Services Rendered
The New Jersey PIP / No Fault Fee Schedule is on the “reasonable and prevailing charges of 75% of providers by region within the state. There are three separate geographical regions. The Fee Schedule is codified at N.J.A.C. 11:3-29.4. Not all procedures and treatments are listed on the Fee Schedule. For unlisted treatments, New Jersey law instructs providers to bill the amount listed for comparable services or equipment in the same region. If there are no sufficiently comparable services listed, the billed amount shall not exceed the “usual, customary and reasonable fee” as determined by the provider. When the same provider performs multiple or bilateral service for the same patient at the same time or during the same appointment, the primary procedure is paid in full, the second procedure is paid at 50% of the normal fee, and all subsequent procedures are paid at 25%. For certain physical therapy / rehabilitation treatments (listed in the appendix to the statute), the maximum billable amount is capped at $90.00 per day.
Pre-Certification of Treatment
For certain soft-tissue back injuries, the New Jersey PIP / No Fault law prescribes specific “care paths” that dictate the standard treatment plan providers must follow to be eligible for reimbursement. The care paths are provided in an appendix to the N.J.A.C. Regulations with charts showing the recommended treatment timeline punctuated by “decision points,” which are points in the course of treatment at which the provider must inform the carrier of his or her treatment plan going forward if he or she believes further treatment is necessary. The carrier can then have an independent physician evaluate the necessity of the additional treatment and approve or deny authorization for it. Only certain procedures require pre-certification, and the carrier must inform the injured party and his or her treatment providers of any pre-certification requirements in advance. If the provider fails to comply with the pre-certification requirements, the carrier may apply a penalty of a 50% reduction of the amount payable for each service rendered.
Dispute Resolution
When a provider’s submitted claims are denied or underpaid, the NJ PIP / No Fault law offers two remedies: binding arbitration or litigation in New Jersey Superior Court. Some carriers first require a provider to appeal the decision through the carrier’s internal appeals process, but this is usually a fruitless endeavor. Still, if a provider is aware that the carrier has a mandatory internal appeals process and fails to submit to it, the carrier can use that as a total defense later at arbitration or litigation. The Commissioner of Insurance of New Jersey designates the organization that handles dispute resolution for all PIP claims. The current organization is Forthright Solutions, which employs full-time dispute resolution professionals. There is a $225.00 filing fee for a Demand for Arbitration with an in-person hearing and $200.00 for a decision based only on supporting documents submitted. The dispute resolution system is preferable to litigation in New Jersey Supreme Court because it does not take nearly as long to obtain a decision and the carrier’s rights to discovery are much more limited. Also, when the carrier loses at arbitration, the carrier has to reimburse the filing fee and pay the provider’s attorney’s fee itself, on top of the principal due. Arbitration awards are binding and can only be appealed to a three-member panel on the grounds that they were “incorrect as a matter of law.”
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