new jersey pip pre-certification process€¦ · what is pre-certification and why is it necessary?...

New Jersey PIP Pre-Certification Process

Presented by: Andrew J. Blair, Esq.

ANDREW J. BLAIR, ESQ.Presents:

New Jersey Pre-Certification Process

What is Pre-Certification and Why is it Necessary?

The definition of pre-certification is:

"Precertification" or "precertification request" means theprocedures in an insurer's approved decision point review planfor the insurer to receive notice and respond to requests forlisted specific medical procedures, treatments, diagnostic tests,other services and durable medical equipment that are notsubject to decision point review and that may be subject tooverutilization.

Andrew J. Blair, Esq.

PIP Collections and Arbitrations (973) 779-2202


This presentation will address:

• The form required for pre-certification requests;

• What treatment requires pre-certification;

• What documentation is required with the pre-certification request;

• Where and how to submit a pre-certification request;

• How long the insurance carrier has to respond to a pre-certification request;

• What to do if the insurance carrier fails to respond to a pre-certification request;

• What to do pending a response to the pre-certification request; and

• What to do if the pre-certification request is denied.




DPRP will provide the majority of information needed for pre-certification.

21 Day Notices will prompt the insurance carrier to send you a copy ofthe DPRP.




Pre-certification is necessary because it is required by the New JerseyAdministrative Code.

Pre-certification gives the insurance carrier an opportunity to reviewthe medical treatment and provide authorization for same.

Approval of pre-certification increases the likelihood that payment willbe received.




Approval of a pre-certification request is on the basis of medicalnecessity and not a confirmation of eligibility.

The insurance carrier can still deny payment if eligibility is notconfirmed.




In the event that you do not request pre-certification of treatment thatdoes not necessarily mean that you will not be reimbursed fortreatment provided.

Specifically, the New Jersey Administrative Code permits the insurancecarrier to apply a 50% penalty to treatment that is eligible forreimbursement that did not have a properly submitted pre-certificationrequest.



What Treatment Requires Pre-Certification?

As mentioned above, the specific treatment that requires pre-certification can be found in the insurance carrier's Decision PointReview Plan.




Treatment that does not require pre-certification:

• Pre-certification is not required within 10 days of the insuredevent or to emergency care – This does NOT guarantee payment;

• Pre-certification is not required for a new patient evaluation;

• Pre-certification is not required for treatment or services thatwere provided prior to the time notification to the insurancecarrier was required




Each insurance carrier has their own individual list of treatment thatrequires pre-certification. However, it is always best to proceed withcaution. So when in doubt, it is better to request pre-certification of aservice that does not require it, instead of not requesting pre-certification and risking the application of a 50% penalty.




In general, typically, pre-certification is required for:

• Non-emergency inpatient or outpatient hospital care;

• Non-emergency surgery;

• Durable medical equipment;

• Extended care and rehabilitation;

• Home health care;

• Infusion therapy;

• Outpatient psychological/psychiatric testing and/or services, includingbiofeedback;




• Physical, occupational, speech, cognitive, or other restorative therapy,or body part manipulation;

• All pain management services, including quantitative drug testing;

• Non-emergency dental restoration;

• Temporomandibular disorders or any oral facial syndrome;

• Outpatient care for soft tissue/disc injuries of the neck, back, orrelated structures;

• Computerized muscle testing;

• Current perceptual testing;




• Temperature gradient studies;

• Work hardening;

• Carpal Tunnel Syndrome;

• Vax D and/or DRX;

• Podiatry;

• Audiology;

• Bone scans;

• Investigations or novel treatment;




• Non-emergency transportation services;

• Schedule II, III, and IV controlled substances;

• Prescriptions;

• Non-medical products, devices, and services not exclusively used formedical purposes;

• Any and all procedures that use an unspecified CPT code; and




• Diagnostic tests:• Brain mapping;

• Brain audio evoked potentials;

• Brain evoked potentials;

• Computer assisted tomograms (CT, CAT scan);

• Dynatron/cybex station/cybex studies;

• Range of muscle motion testing;

• Video-fluoroscopy;

• H-reflex studies;

• Sonogram/ultrasound;




• Needle electromyography (needle EMG);

• Nerve conduction velocity (NCV);

• Somatosensory evoked potential;

• Magnetic resonance imaging (MRI);

• Electroencephalogram;

• Visual evoke potential;

• Thermogram/thermography; and

• Any other diagnostic test that is subject to the requirements of Decision PointReview by the New Jersey Administrative Code.




This list is intended to be a guide and may not include allprocedures that are subject to pre-certification. It is important toreview each individual Decision Point Review Plan to determineexactly what services and/or equipment requires pre-certification.



What Form and Documentation is Necessary to Submit to Support a Pre-Certification Request?

• APTP Form;• All supporting documentation:

• Most recent evaluation;• Corresponding daily SOAP notes; and• Relevant diagnostic test results.



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Where do you Submit a Pre-Certification Request?

This varies by insurance carrier. This information will be locatedwithin the insurance carrier's Decision Point Review Plan.

It is important to retain proof of the submission of the pre-certification request.

Always check to make sure that you are utilizing the correct faxnumber and that you received a successful transmission.



How Long does the Insurance Carrier have to Respond to a Pre-Certification Request?

Pursuant to the New Jersey Administrative Code, the insurance carrier has 3 business days to respond to a pre-certification request.

Following the expiration of the 3 business days, if a response to the pre-certification request is not received, you must submit a New Jersey PIP Pre-Service Appeal Form to the insurance carrier.

It is important to request the treatment starting after the 3rd business day.



What if the Insurance Carrier Fails to Respond to a Pre-Certification Request?

If the insurance carrier fails to provide a response to the pre-certification request, you must submit a New Jersey PIP Pre-Service Appeal Form to the insurance carrier.

At this point, you may continue to treat your patient.



Can you Treat Prior to Receiving a Response to the Pre-Certification Request?

If you submit a pre-certification request for a date range startingbefore the expiration of the 3 business days, if the treatment isdetermined to be medically necessary, the treatment prior to theexpiration of the 3 business days may be subject to a 50% pre-certification penalty.

Following the expiration of the 3 business days, you should submita pre-service appeal to the insurance carrier as addressed above.In this circumstance, you can continue to treat your patientwithout an interruption in services.



What if Pre-Certification is Denied?

In the event that a pre-certification request is denied, you mustthen submit a New Jersey PIP Pre-Service Appeal Form to theinsurance carrier.

Treatment cannot continue until, either, the insurance carrierresponds to the pre-service appeal or 14 days from the date thatthe pre-service appeal was submitted, whichever comes first.




It is best to request pre-certification approximately 3 weeks in advanceto allow time for the appeal process, whenever possible.

This will avoid the lapse in treatment if your pre-certification request isdenied.




Example with a lapse of treatment:

If the patient began treatment on March 1st, pre-certificationwas requested for treatment through April 1st. On March 25th,the patient was re-evaluated and a second pre-certificationrequest was submitted for treatment from April 1st through May1st. The insurance carrier denied the pre-certification request onMarch 27th. On March 27th, the medical provider appealed thedenial. The treating provider cannot treat the patient until theinsurance carrier responds to the appeal or April 10th, whichevercomes first.




Example of avoiding a lapse in treatment:

If the patient began treatment on March 1st, pre-certification wasrequested for treatment through April 1st. On March 12th, thepatient was re-evaluated and a second pre-certification requestwas submitted for treatment from April 1st through May 1st. Theinsurance carrier denied the pre-certification request on March15th. On March 15th, the medical provider appealed the denial.The treating provider cannot treat the patient until the insurancecarrier responds to the appeal or April 1st, whichever comesfirst.




Again, it is important to note that if a pre-certification is denied,you cannot treat prior to receiving a response to the pre-serviceappeal or 14 days, whichever comes first.

If the insurance carrier responds to the appeal prior to the 14days, you can, once again, commence treatment.

This is a new rule that went into effect with the new appealsprocess as of April 17, 2017.




When filing a pre-service appeal, all supporting documentationshould be included. The Administrative Code requires medicalproviders to submit the appeal forms and any supportingdocumentation to the insurance carrier pursuant to its DecisionPoint Review Plan.




The documentation that is required to be submitted with a pre-service appeal is:

• The original APTP form with all attachments;

• The APTP decision/response document; and

• The appeal narrative.

Additional documentation that may be attached to the pre-service appeal mayinclude, but not be limited to:

• IME report;

• Diagnostic reports;

• Peer review report; and

• Any other supporting documentation.




In the event that you treat prior to the insurance carrier's responseto the appeal or 14 days, the insurance does not have toreimburse for the treatment and this voids the Assignment ofBenefits. If the Assignment of Benefits is voided, it is impossible tocollect payment.




If you receive a denial of pre-certification based upon medicalnecessity and properly submit a pre-service appeal for same, youcan avoid having to file a post-service appeal for the same issue ofmedical necessity.

This will not only save you time by not having to file an additionalappeal, but will permit you to file a Demand for Arbitration, ifnecessary, much faster.



Resources• Attending Provider Treatment Plan Form:

• http://www.state.nj.us/dobi/pipinfo/aptp_ver160310.pdf

• Pre-Service Appeal Form:• http://www.state.nj.us/dobi/pipinfo/preserviceappeal_170208.pdf

• Post-Service Appeal Form:• http://www.state.nj.us/dobi/pipinfo/postserviceappeal_170208.pdf

• DOBI’s Frequently Asked Questions• http://www.state.nj.us/dobi/pipinfo/internalappealrulechanges.html• (last updated 3/24/2017)

• DOBI’s Comments and Responses on the Proposed Rule Changes (from10/17/2016)• 2016 NJ REG TEXT 407380 (NS)• 48 N.J.R. 2144(a)



http://www.state.nj.us/dobi/pipinfo/internalappealrulechanges.html

Questions?



Please Contact Us

Andrew J. Blair, Esq.PIP Collections and Arbitrations

[email protected](973) 779-2202

mailto:[email protected]

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