N.J. Admin. Code § 11:3-25.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:3-25.6 - Standards for adjustment of reduction

(a) Notwithstanding the reductions set forth in 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 untimely notice under this subchapter or has established a pattern of untimely notice;

2. The cost of medical treatment provided by the treating health care provider between the time treatment commenced, when notice was due and when it was provided;

3. The injured party was a pedestrian who did not have PIP coverage as the named insured or resident relative under another policy and the circumstances are such that additional time is necessary to identify the policy under which coverage is being provided;

4. Any potential adverse impact on the public; and

5. Such other factors as the insurer may determine.

(b) Within 60 days of receipt of notice, or such additional time as may be afforded under N.J.S.A. 39:6A-5g, the insurer shall give the treating health care provider notice of its final determination as to payment, reduction or denial of payment of an eligible charge. Such notice shall be clearly labeled "Final Determination," and it shall refer clearly to the injured party, the insured, the claim number, the date of accident, the date of first treatment, the date notice of the commencement of treatment was made and the acceptance or rejection of any of the standards of adjustment of the reduction in (a) above and 11:3-25.5(b).

N.J. Admin. Code § 11:3-25.6

Amended by R.1998 d.591, effective 12/21/1998 (operative March 22, 1999).
See: 30 New Jersey Register 3202(a), 30 New Jersey Register 4390(b).
Substituted references to health care providers for references to medical providers throughout.