As of July 11, 2006, certain laws have changed regarding handling of claims, claims payment appeals, prior authorization processes, utilization management (UM) appeals rights and obligations, and information about clinical guidelines and claims submissions procedures that carriers must have readily available for health care providers. The existing law was amended and supplemented by P.L. 2005, c. 352 (Chapter 352).
The Department does not yet have rules in place to implement the requirements of Chapter 352. However, the Department has begun issuing bulletins to provide guidance to both carriers and health care providers. The Department has also begun issuing forms to help carriers and health care providers comply with the new law. This includes:
Bulletin 10-32: P.L. 2005, c. 352 – Health Claims Authorization, Processing and Payment Act (HCAPPA) – Change of Health Care Provider Application to Appeal a Claim Determination Form NEW
Bulletin 06-16: P.L. 2005, C. 352 – Health Claims Authorization, Process and Payment Act – Forms, Effective Date, and an Update on Arbitration
Bulletin 06-17: P.L. 2005, C. 352 – Health Claims Authorization, Process and Payment Act (HCAPPA) – Forms
Bulletin 07-14: P.L. 2005, C.352 – Health Claims Authorization, Processing and Payment Act (HCAPPA) – Arbitration Program
| Claims Payment Dispute Arbitration |
| A new health claims binding arbitration program for doctors, hospitals and other medical service and equipment providers is now available. The Program for Independent Claims Payment Arbitration (PICPA) is accepting applications and is operated for the Department by MAXIMUS, Inc. |
On or about July 2, 2007, parties with claims eligible for arbitration may complete an application accessible online at https://dispute.maximus.com/nj/indexNJ, and submit the application, together with required review and arbitration fees, to the PICPA.
The completed online applications can be printed and/or saved for the applicant's own records. Supporting documentation may be submitted online, faxed or mailed using the case number generated through the online submission process.
The Department of Banking and Insurance is providing a series of questions and answers that may be helpful for interested parties. The questions have been separated into categories for easier reference. Some questions appear in more than one category because of overlap in the subject matter. Please note the following about the responses:
| Claims Payment: | Program for Independent Claims Payment Arbitration (PICPA) |
| Utilization Management: | Initial Determinations, Staffing and Readily-accessible Information |
| Utilization Management: | UM Appeals and the Independent Health Care Appeals Program (IHCAP) |
The following instructions are designed to help health care providers or carriers, as appropriate, utilize the forms on a routine basis.
| January 2018 | January 2017 |
| February 2018 | February 2017 |
| March 2018 | March 2017 |
| April 2018 | April 2017 |
| May 2018 | May 2017 |
| June 2018 | June 2017 |
| July 2018 | July 2017 |
| August 2018 | August 2017 |
| September 2018 | September 2017 |
| October 2018 | October 2017 |
| November 2018 | November 2017 |
| December 2018 | December 2017 |
| A claim is eligible for arbitration if: | |
| 1. | The claim was submitted to an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, prepaid prescription service organization, or its agent, including an organized delivery system (ODS) or a third party administrator (TPA), for payment under a health benefits plan issued in this State. Claim disputes submitted to a self-funded entity, the State Health Benefits Program, a dental service corporation, or a dental plan organization (DPO) are not eligible for resolution through the PICPA; |
| 2. | The claim arises from health care services rendered on or after July 11, 2006; |
| 3. | The health care provider appealed the denied claim to the carrier by submitting the Health Care Provider Application to Appeal a Claims Determination available above to access the carrier’s internal claims appeal process; |
| 4. | The carrier’s internal claims appeal process was completed, or the carrier failed to comply with the processing and review timeframes with respect to the appeal and the health care provider has documentation supporting that contention; |
| 5. | When aggregating claims (for the purpose of reaching the minimum $1,000 dispute threshold), a health care provider aggregates claims by carrier and covered person or by carrier and CPT code; and |
| 6. | The health care provider timely submits the application for arbitration and the appropriate fees. |