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What to Do after an Auto Accident In the event that a named insured or eligible insured person is injured in an auto
accident, such person or their health care provider should call Parkway
Insurance Company at 1-800-821-1818. What is Decision Point Review? Pursuant to N.J.A.C. 11:3-4, the New Jersey Department of Banking and Insurance has published a standard course of treatment, known as Care Paths, for soft tissue injuries of the neck and back, collectively referred to as Identified Injuries. The Care Paths provide that treatment be evaluated at certain intervals called Decision Points. Decision Point Review means those junctures in the treatment of Identified Injuries where a decision must be made about the continuation or choice of further treatment. Hexagonal boxes represent these intervals in the Care Paths. The Care Paths and accompanying rules are available on the Internet on the Department’s website at www.nj.gov/dobi/aicrapg.htm. In addition, the administration of certain diagnostic tests is subject to Decision Point Review regardless of the diagnosis. The following tests are subject to Decision Point Review: Needle electromyography (needle EMG) Somasensory evoke potential (SSEP) Visual evoked potential (VEP) Brain audio evoked potential (BAEP) Brain Evoked Potential (BEP) Nerve Conduction velocity (NCV) H-reflex study Electroencephalogram (EEG) Videofluoroscopy Magnetic resonance imaging (MRI) Computer assisted tomographic studies (CT, CAT scan) Dynatron/Cyber station/Cybex Sonograms/ultrasound Thermography/thermograms Brain mapping when done in conjunction with appropriate neurodiagnostic testing
Decision Point Review Requirements Our approval of Decision Point Review requests will be based exclusively on medical necessity, as determined by using standards of good practice and standard professional treatment protocols. Our final determination of the medical necessity of any disputed issues shall be made by a physician or dentist, as appropriate for the injury and treatment contemplated. The Named Insured and/or Eligible Injured Person and/or their health care provider must provide us with reasonable prior notice of the anticipated services, treatment and diagnostic tests as well as the appropriate clinically supported findings to facilitate timely approval. Should you or your health care provider fail to submit a request for Decision Point Review or fail to provide clinically supported findings to support the treatment, diagnostic test or durable medical equipment requested, your medical bills for such treatment will be subject to a penalty co-payment of 50% even if the services are determined to be medically necessary. This co-payment is in addition to the mandatory and/or selected deductible and co-payment applicable to this policy under the Personal Injury Protection coverage. When appropriate, the health care provider may submit a comprehensive treatment plan for consideration. This additional co-payment will not apply if we have received proper notice, supporting documentation and have failed to act within three (3) business days to authorize or deny reimbursement of further treatment or tests. Decision Point Review Process Through our medical services vendor, GENEX Services, Inc., we will review all information submitted, render a decision and notify the insured and/or medical provider, within three (3) business days, whether we will authorize the additional treatment or diagnostic test. Any denial of reimbursement for further medical treatment or tests will be based on the determination of a physician or dentist, as appropriate for the injury and treatment contemplated. Decision Point Review shall be requested by clicking here and completing the attached Attending Providers Treatment Plan form. In order for GENEX to complete their review, you are required to submit all requests on the Attending Physicians Treatment Plan form in accordance with DOBI Order No. A-104-143. A copy of this form can be found on the DOBI website: www.nj.gov/dobi/ORDERS/treatmentform.pdf, Parkway Insurance Company’s website: www.parkway.com or by contacting GENEX Services, Inc. @ 1-888-670-2088. In the event we receive insufficient information to support the requested services, an administrative denial will be issued and will continue until we receive documentation sufficient to evaluate the request for such diagnostic test, treatment or services. All information should be mailed to GENEX Services, Inc., 440 E. Swedesford Road, Suite 2045, Wayne, PA 19087 or faxed to 1-888-670-2097. Please note that the Decision Point Review requirements do not apply to treatment or diagnostic tests within ten (10) days of the accident or administered during emergency care. However, we are only responsible for payment of medically necessary care. If we fail to take any action or fail to respond within three (3) business days after receiving the required notification and supporting medical documentation at a decision point, then the treating health care provider is permitted to continue the course of treatment until we provide the required notice. PPO Networks Our medical services vendor, GENEX Services, Inc., has established PPO Networks which include providers in all specialties, hospitals, out patient facilities, and urgent care centers throughout the entire state. The use of these networks is strictly voluntary and the Named Insured and/or Eligible Injured Person always has the option in choosing their health care provider. The RN Case Manger assigned to your claim will provide the Named Insured and/or Eligible Injured Person with a current PPO Network list. Voluntary Networks for Identified Injuries Our medical service vendor, GENEX Services Inc. has established networks of pre-approved vendors, which can be recommended for the provision of certain services, diagnostic tests, i.e., magnetic resonance imagery, computer assisted tomography, the electrodiagnostic tests listed in N.J.A.C. 11:3-4.5(b) 1 through 3 except when performed in conjunction with a needle EMG by the treating physician, durable medical equipment with a cost or monthly rental in excess of $50.00; or prescription drugs and supplies. These pre-approved vendors are tested and monitored to ensure that the highest quality goods and services are provided. You are encouraged, but not required, to obtain certain services, diagnostic tests, prescription supplies and/or durable medical equipment from one of the pre-approved vendors. Should you choose a designated provider or supplier for diagnostic tests, prescription supplies, and/or durable medical equipment, you will be fully reimbursed consistent with the terms of our policy. Additionally, your policy deductible and co-payment will be waived. Should you not use a designated provider or supplier for medically necessary goods or services, we will provide reimbursement but only up to 70% of the lesser of: (1) the charge or fee provided for in N.J.A.C. 11:3-29, or (2) the vendor’s usual, customary and reasonable charge or fee. Internal Appeal Procedure If we deny a Decision Point Review request for any medical services, procedures, treatments, or diagnostic tests under your policy, you or your health care providers are entitled to seek from us a reconsideration of the decision. You or your health care provider must request a reconsideration and include any additional information about the treatment or test requested within two (2) weeks of our denial. Upon request for reconsideration, we shall have no longer than three (3) business days to issue our decision. A GENEX Medical Director shall review all requests for reconsideration and we shall be bound by the Medical Director's decision. The Medical Director is available by telephone at 1-888-670-2088 and/or fax at 1-888-670-2097 between 8:00 a.m. and 5:30 p.m. Eastern Standard Time every business day. All requests for reconsideration should be submitted in writing to GENEX Services, Inc., 440 E. Swedesford Road, Suite 2045, Wayne, PA 19087 or faxed to 1-888-670-2097. If we and any person seeking Personal Injury Protection Coverage do not agree as to the recovery of Personal Injury Protection Coverage under this policy, then the matter may be submitted to Alternate Dispute Resolution pursuant to N.J.A.C. 11:3-5. For further information on Dispute Resolution, you may access the National Arbitration Forum @ www.arbitration-forum.com. What is Mandatory Pre-certification? Pursuant to New Jersey Regulation (N.J.A.C. 11:3-4.8), insurers will require pre-certification of certain treatments or diagnostic tests for diagnoses or treatments not included in the Care Paths. Pre-certification is a program described in your policy, by which the medical necessity of certain diagnostic tests, medical treatments, and procedures are subject to prior authorization, utilization review and/or case management. Pre-certification does not apply to treatment or diagnostic tests administered during emergency care or during the first ten (10) days after the accident causing the injury. However, we are only responsible for payment of medically necessary care. The following are procedures, treatments, diagnostic tests, prescription supplies, or other potentially covered medical expenses for which pre-certification is required:
Pre-certification Requirements Our approval of requests for pre-certification will be based exclusively on medical necessity, as determined by using standards of good practice and standard professional treatment protocols, including but not limited to, the Care Paths recognized by the Commissioner of Banking and Insurance. Our final determination of the medical necessity of any disputed issues shall be made by a physician or dentist, as appropriate for the injury and treatment contemplated. Pre-certification shall be requested by clicking here and completing the attached Attending Physicians Treatment Plan form in accordance with DOBI Order No. A-104-143. A copy of this form can be found on the DOBI website: www.nj.gov/dobi/ORDERS/treatmentform.pdf, Parkway Insurance Company’s website: www.parkway.com, or by contacting GENEX Services, Inc. @ 1-888-670-2088. The Named Insured and/or Eligible Injured Person and/or their health care provider must provide us with reasonable prior notice of the anticipated services, treatments and procedures outlined above, as well as, the appropriate clinically supported findings to facilitate timely approval. When appropriate, the health care provider may submit a comprehensive treatment plan for pre-certification. Should you or your health care provider fail to submit a request for Pre-certification or fail to provide clinically supported findings to support the treatment, diagnostic test or durable medical equipment requested, your medical bills for such treatment will be subject to a penalty co-payment of 50% even if the services are determined to be medically necessary. This co-payment is in addition to the mandatory and/or selected deductible and co-payment applicable to your policy under the Personal Injury Protection Coverage. This additional co-payment will not apply if we have received proper notice, supporting documentation and have failed to act within three (3) business days to authorize or deny reimbursement for further treatment or tests. Pre-certification Review Process As Parkway's medical services vendor, GENEX Services Inc. will review all information submitted, render a decision, and notify the insured and/or medical provider, within three (3) business days, whether or not we will authorize the additional treatment or diagnostic test. Any denial of reimbursement for further medical treatment or tests will be based on the determination of a physician or dentist, as appropriate for the injury and treatment contemplated. In the event we receive insufficient information to support the requested services, an administrative denial will be issued and will continue until we receive documentation sufficient to evaluate the request for such diagnostic test, treatment or services. All information should be mailed to GENEX Services, Inc., 440 E. Swedesford Road, Suite 2045, Wayne, PA 19087, or faxed to 1-888-670-2097. Please note that the Pre-certification Review requirements do not apply to treatment or diagnostic tests within ten (10) days of the accident or administered during emergency car. However, we are only responsible for payment of medically necessary care. Should we fail to take any action or fail to respond within three (3) business days after receiving the required notification and supporting documentation with a pre-certification request, then the treating health care provider is permitted to continue the course of treatment until we provide the required notice. Voluntary Pre-certification Healthcare providers are encouraged to participate in a voluntary pre-certification process by providing GENEX Services Inc. with a comprehensive treatment plan for both identified and other injuries. GENEX Services Inc. will utilize nationally accepted criteria and the Care Paths to work with the health care provider to certify a mutually agreeable course of treatment including itemized services and a defined treatment period. In consideration for the healthcare providers participation in the voluntary pre-certification process, all bills submitted, when consistent with the precertified services, will be paid so long as they are in accordance with PIP medical fee schedule set forth in N.J.A.C. 11:3-29.6. In addition, having an approved treatment plan means that as long as the treatment is consistent with the plan, additional notification to GENEX Services Inc. is not required. PPO Networks Our medical service vendor, GENEX Services Inc. has established PPO networks, which include providers in all specialties, hospitals, out patient facilities, and urgent care centers throughout the entire state. The utilization of these networks is strictly voluntary and the choice of the health care provider is always made by the Named Insured and/or Eligible Injured Person. The RN Case Manager assigned to your claim will provide the Named Insured and/or Eligible Injured Person with a current PPO Network list. Voluntary Networks for Non-Identified Injuries Our medical service vendor, GENEX Services Inc. has established networks of pre-approved vendors, which can be recommended for the provision of certain services, diagnostic tests, i.e., magnetic resonance imagery, computer assisted tomography, the electrodiagnostic tests listed in N.J.A.C. 11:3-4.5(b) 1 through 3 except when performed in conjunction with a needle EMG by the treating physician, durable medical equipment with a cost or monthly rental in excess of $50.00; or prescription drugs and supplies. These pre-approved vendors are tested and monitored to ensure that the highest quality goods and services are provided. You are encouraged, but not required, to obtain certain services, diagnostic tests, prescription supplies and/or durable medical equipment from one of the pre-approved vendors. Should you choose to use a vendor that is not part of the approved networks, we will provide reimbursement for diagnostic tests, prescription supplies, and/or durable medical equipment but only up to 70% of the lesser of the following: (1) the charge or fee provided for in N.J.A.C. 11:3-29, or (2) the vendors usual, customary and reasonable charge or fee. Should you choose a designated vendor, you will be fully reimbursed consistent with the terms of our policy. Additionally, your policy deductible and co-payment will be waived. Internal Appeals Procedure If we deny a request to pre-certify any medical services, procedures, treatment, or diagnostic tests under your policy, you or your health care providers are entitled to seek from us a reconsideration of the decision. To access the voluntary appeal procedure, you or your health care providers must request a reconsideration and include any additional information about the treatment or test requested within two (2) weeks of our denial. Upon request for reconsideration, we shall have no longer than three (3) business days to issue our re-determination. GENEX's Medical Director shall review all requests for reconsideration and we shall be bound by the Medical Director's decision. The Medical Director is available to consult with the treating health care provider during the reconsideration. All requests for reconsideration should be submitted in writing to GENEX Services, Inc., 440 E. Swedesford Road, Suite 2045, Wayne, PA 19087, or faxed to 1-888-670-2097. If we and any other person seeking Personal Injury Protection Coverage do not agree as to the recovery of Personal Injury Protection Coverage under this policy, then the matter may be submitted to a Alternate Dispute Resolution Organization pursuant to N.J.A.C. 11:3-5. For further information on Dispute Resolution, you may access the National Arbitration Forum @ www.arbitration-forum.com. Independent Medical Examinations/ Second Opinion We may require a physical or mental examination before we determine whether to provide coverage for further treatment of tests. Should such an independent physical or mental examination be required, the examination will be scheduled within seven (7) calendar days from receipt of the request for additional treatment unless the injured party agrees to extend the time period. A health care provider in the same discipline shall conduct the examination at a location reasonably convenient to the injured person. You and/or your treating health care provider must, upon our request, or the request of our designees, provide medical records and other pertinent information to the health care provider conducting such medical examination. The requested records shall be provided no later than the time of the examination or before the scheduled exam. In addition, if an independent physical or mental examination is required, medically necessary treatment shall proceed while the examination is being scheduled and until the results become available. Should the Eligible Injured Person have two or more unexcused failures to attend the scheduled exam, notification will be immediately sent to the Eligible Injured Person or his or her designee, and all providers treating the Eligible Injured Person for the diagnosis (and related diagnosis) contained in the Attending Physician Treatment Plan form. The notification will place the Eligible Injured Person on notice that all future treatment, diagnostic testing or durable medical equipment required for the diagnosis (and related diagnosis) contained in the Attending Physicians Treating Plan form will not be reimbursable as a consequence for failure to comply with the plan. Should you need special accommodations due to a disability, please contact us at least three (3) business days before your scheduled examination date for any special arrangements, i.e. transportation needs, etc. Upon completion of the Independent Medical Examination, we will notify the injured person and the provider within three (3) business days both telephonically and in writing. All requests for Independent Medical Examination will be handled through GENEX Services, Inc., 440 E. Swedesford Road, Suite 2045, Wayne, PA 19087, telephone 1-888-670-2088, or fax 1-888-670-2097. Assignment of Benefits Medical expense benefits shall not be assignable, except to a provider of service benefits who obtains our consent in accordance with the terms of the insurance policy. Our consent shall be conditioned upon compliance with the policy terms including: prompt notification of the commencement of treatment of any insured; providing notice to us about proposed treatment or testing as required by our plan; our being provided with requested and complete medical notes, tests results and progress notes which are related to the injuries for which reimbursement is being sought. In addition, the provider is required to hold the injured person and us harmless for any reduction of benefits caused by the provider's failure to comply with the terms of our Decision Point Review and Precertification Plan. Our consent to assignment of benefits shall be automatic for providers of service benefits who are contracted members of a provider group through GENEX Services, Inc. Additional Information about Personal Injury Protection Coverage, Care Paths, Decision Point Review and Pre-certification If you would like to know more about Care Paths, Decision Point Review and the medical procedures, treatments, diagnostic tests requiring pre-certification, information is available by calling Parkway Insurance Company at 1-800-821-1818. Should you need assistance or have any questions regarding your PIP benefits, please do not hesitate to call. Note: No coverage is provided by this summary of questions and answers, nor can it be construed to replace any provision of your policy. You should read your policy and review your declarations page for complete information on the coverages you are provided. If there is any conflict between the policy and this summary, the provisions of the policy shall prevail. |
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