N.J. Admin. Code § 11:3-29.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:3-29.1 - Purpose and scope

(a) Every policy of automobile insurance and motor bus insurance issued in this State shall provide that the automobile insurer's limit of liability for medically necessary expenses payable under PIP coverage, and the motor bus insurer's limit of liability for medically necessary expenses payable under medical expense benefits coverage, is the fee set forth in this subchapter or the usual, customary and reasonable fee, whichever is less.

(b) This subchapter implements the provisions of N.J.S.A. 39:6A-4.6 to establish medical fee schedules on a regional basis for the reimbursement of health care providers providing services or equipment for medical expense benefits for which payment is required to be made by automobile insurers under PIP coverage and by motor bus insurers under medical expense benefits coverage.

(c) This subchapter applies to all insurers who issue policies of automobile insurance containing PIP coverage and policies of motor bus insurance containing medical expense benefits coverage.

(d) This subchapter does not apply to the following:

1. Other coverages contained in an automobile or motor bus insurance policy such as coverage for bodily injury liability;

2. Any other kind of insurance including health insurance, even when the health insurer may be required pursuant to its health insurance contract to pay benefits to, or on behalf of, a person who sustained bodily injury as a result of an accident while occupying, entering into, alighting from or using an automobile or motor bus, or as a pedestrian, caused by an automobile or motor bus or an object propelled by or from an automobile or motor bus;

3. Medical services or equipment provided outside of the geographic boundaries of New Jersey except as set forth in N.J.A.C. 11:3-29.4(d)2; and

4. Inpatient services provided by acute care hospitals, trauma centers, rehabilitation facilities, other specialized hospitals, residential alcohol treatment facilities and nursing homes, except as specifically set forth in this subchapter.

N.J. Admin. Code § 11:3-29.1

Amended by R.1993 d.25, effective 1/4/1993.
See: 24 N.J.R. 3605(a), 25 N.J.R. 140(a).
Added motor bus insurers under medical expense benefits coverage.
Amended by R.2001 d.158, effective 5/21/2001.
See: 32 N.J.R. 4332(a), 33 N.J.R. 226(a), 33 N.J.R. 1590(a).
Amended by R.2007 d.305, effective 10/1/2007.
See: 38 N.J.R. 3437(a), 39 N.J.R. 4126(c).
In the introductory paragraph of (c), substituted "This subchapter does" for "These fee schedules do"; in (c)2, deleted "and" from the end; in (c)3, substituted "; and" for the period at the end; and added (c)4.
Notice of Stay of Implementation: See: 39 N.J.R. 4849(a).
By Order of the Appellate Division of the Superior Court of New Jersey entered on September 28, 2007, the implementation of amendments to this rule published in the October 1, 2007 New Jersey Register at 39 N.J.R. 4126(c) was stayed pending a decision in the matter of Alliance for Quality Care, Inc., et al. v. New Jersey Department of Banking and Insurance, Docket No. A33-07 T3, now pending before the Appellate Division.
Amended by R.2012 d.187, effective 11/5/2012 (operative January 4, 2013).
See: 43 N.J.R. 1640(a), 44 N.J.R. 383(a), 44 N.J.R. 2652(c).
Added new (a); recodified former (a) through (c) as (b) through (d); and in (d)4, inserted ", except as specifically set forth in this subchapter".