N.J. Admin. Code § 11:3-4.9

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

Section 11:3-4.9 - Assignment of benefits; public information

(a) Pursuant to N.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policy to a provider of service benefits. Insurers may file for approval policy forms that include reasonable procedures for restrictions on the assignment of personal injury protection benefits and duties under the policy, consistent with the efficient administration of the coverage and the prevention of fraud. Insurers may not prohibit the assignment of benefits to providers. Reasonable restrictions may include, but are not limited to:

1. A requirement that as a condition of assignment, the provider agrees to follow the requirements of the insurer's decision point review plan for making decision point review and precertification requests;

2. A requirement that as a condition of assignment, the provider shall hold the insured harmless for penalty co-payments imposed by the insurer based on the provider's failure to follow the requirements of the insurer's decision point review plan; and/or

3. A requirement that as a condition of assignment, the provider agrees to submit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5.

(b) Insurers may file policy language requiring that providers who are assigned benefits by the insured or have a power of attorney from the insured make an internal appeal pursuant to N.J.A.C. 11:3-4.7B prior to making a request for dispute resolution in accordance with N.J.A.C. 11:3-5.

(c) An insurer shall identify documents containing proprietary information in its decision point review plan submission. Documents containing proprietary information shall be confidential and shall not be subject to public inspection and copying pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-1 et seq. The Department shall notify the insurer prior to responding to any public record request for proprietary information.

N.J. Admin. Code § 11:3-4.9

Amended by 48 N.J.R. 2144(a), effective 10/17/2016