New Jersey Auto Reform Details...

 

IMPORTANT NOTICE: AMENDMENTS TO N.J.A.C 11:3-4

The New Jersey Automobile Insurance Cost Reduction Act of 1998 (“AICRA” – N.J.A.C. 11:3-4) was enacted to provide Personal Injury Protection (PIP) benefits and reimbursement to medical providers for diagnosis and treatment of injuries sustained as a result of covered automobile accidents.

Recent amendments to N.J.A.C. 11:3-4 have become effective October 27, 2004, and will be reflected in the following revised Decision Point Review and Precertification guidelines. \

Precertification and Decision Point Review requests received from health care providers through 12/31/04 will continue to be handled with no change as part of our “Phase In” plan. Effective 1/1/05, all provider requests submitted must utilize the revised Decision Point Review and Precertification guidelines.

However, per Order A04-143 issued by the New Jersey Department of Banking and Insurance, the form must be used by all treating providers effective 10/27/04. This form is available for your use on our website, and can also be viewed and downloaded at the Department of Banking and Insurance (DOBI) website.

Introduction:

Pursuant to N.J.A.C. 11:3-4, et seq, as amended, medical providers are required to provide notification for certain ordered tests, or services performed on patients. This notification is provided in connection with Decision Point Review and Precertification. Hoover Rehabilitation Services, Inc. is requested by insurance carriers to be the Utilization Review Organization involved with the Decision Point Review/Precertification process. Comprehensive Information Packets are sent to involved Providers, Patients and Legal Counsel (See “Dear Dr. Letter” and Patient Letter) Decision Point Review/ Precertification does not apply until the 10th day following the MVA and does not apply to Emergency Care.

Decision Point Review Process:

Pursuant to N.J.A.C. 11:3-4, et seq., as amended, the New Jersey Department of Banking and Insurance (Department) has published standard courses of treatment, Care Paths (http://www.nj.gov/dobi/attpip.htm), for soft tissue injuries of the neck and back, collectively referred to as the Identified Injuries. (For a list of Identified Injuries by ICD-9 codes, see Exhibit A. For Further Information, refer to Glossary of Terms.) N.J.A.C. 11:3-4, et seq., as amended also establishes guidelines for the use of certain diagnostic tests. The Care Paths provide that treatment be evaluated at certain intervals called Decision Points. On the Care Paths, Decision Points are represented by hexagonal boxes. At Decision Points, providers must provide information about further treatment they intend to provide (Decision Point Review). In addition, the administration of any test on the list in Exhibit B also requires Decision Point Review regardless of the diagnosis. The Care Paths and accompanying rules are available on the Internet on the Department's website at http://www.nj.gov/dobi/attpip.htm or by calling Hoover Rehabilitation Services, Inc. at 1-877-704-4440. If a Provider fails to submit requests for Decision Point Reviews, or fails to provide clinically supported findings that support the request, payment of submitted bills will be subject to a penalty co-pay of 50%, even if the services are determined to be medically necessary.
Note: Per Order A04-143 issued by the New Jersey Department of Banking and Insurance, the ATTENDING PROVIDER TREATMENT PLAN form must be used by all treating providers effective 10/27/04.

Mandatory Precertification:

If a patient does not have an Identified Injury, the Provider is required to obtain precertification of all services itemized in Exhibit B. If the Provider fails to precertify such services or fails to submit clinically supported findings to support the request, payment of Provider bills will be subject to a penalty co-pay of 50%, even if the services are determined to be medically necessary. Providers are encouraged to maintain communication with Hoover Rehabilitation Services, Inc. on a regular basis as precertification requirements may change. For your convenience, the Hoover Rehabilitation Services, Inc. website, www.hooverinc.com contains Precertification requirements, or, we can be reached at 1-877-704-4440.
 

Voluntary Precertification:

Providers are encouraged to participate in a Voluntary Precertification process by providing Hoover Rehabilitation Services, Inc. with a comprehensive treatment plan for both identified and other injuries. Hoover Rehabilitation Services, Inc. will utilize nationally-accepted criteria and the Care Paths to work with Providers to certify a mutually agreeable course of treatment to include itemized services and a defined treatment period. In consideration of the Provider's participation in the Voluntary Precertification process, the bills submitted, when consistent with the precertified services, will be paid without utilization audit. In addition, having an approved treatment plan means that as long as treatment is consistent with the plan, additional notification to Hoover Rehabilitation Services, Inc. at Decision Points is not required. As the Provider continues to participate in the Voluntary Precertification process for subsequent services, payment for precertified services will be made without utilization audit (Flow Chart of Precertification & Decision Point Review Protocols).
 

How to Submint Decision Point/Precertification Requests:

In order to complete our review, we require that the Provider present us with any past medical history that is available. We also require the diagnosis, all x-ray and other test results that may have been completed, and documentation of all treatment provided to date. Please indicate any tests or treatment anticipated over the next 30 days. Providers MUST COMPLETE AND FORWARD a “ATTENDING PROVIDER TREATMENT PLAN” form. This form must be accompanied with appropriate progress notes, and results of diagnostic tests or studies relative to the requested services. It can be faxed to 570-283-1637. We encourage that any questions regarding the process be addressed by calling our Precertification Department at 1-877-704-4440 or e-mailing jdimaria@hooverinc.com.Our review of Decision Point/Precertification requests and voluntary precertification requests will be completed within three business days of receipt of the necessary information. Notice of certification will be made to the Provider office by telephone and confirmed in writing. If we fail to make notification within three business days, the Provider may continue with the test or treatment until a final determination is communicated. In addition, if an independent physical or mental examination is required, treatment may proceed while the exam is being scheduled and the results become available (DECISION POINT REVIEW SYSTEM).

Review Outcomes:

· Requested service is certified/approved.
· In the event we receive insufficient information that does not support the requested service, an administrative denial will be issued and will continue until we receive documentation sufficient to evaluate the request for the diagnostic test or treatment service. Once we receive sufficient documentation a decision will be communicated to the Provider within 3 days of receipt of the documentation.
· Any denial of reimbursement for further treatment or testing will be made by a physician or dentist.
· In the event that we must amend the requested services (either frequency, duration, intensity or place of service or treatment), The Provider's office will be notified by telephone and confirmed in writing and a Hoover Rehabilitation Services, Inc. physician advisor will be available to discuss the case with the Provider.
· Pursuant to N.J.A.C. 11:3-4, et seq., as amended and the patient's/Insured's policy: Failure to request decision point review or precertification where required or failure to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested shall result in additional co-payment not to exceed 50% of the eligible charge for medically necessary diagnostic tests, treatments or durable medical goods that were provided between the time of notification to the insurer was required and the time that proper notification is made and the insurer has an opportunity to respond in accordance with its approved decision point review plan.
 

Reconsideration Process:
(Hoover Reconsideration/Appeal Process)

If the Provider request does not meet certification criteria, clinical rationale for this determination is available upon request. Providers are encouraged to utilize Hoover's internal review process for reconsideration by contacting Hoover Rehabilitation Services, Inc. at 1-877-704-4440 (As reflected in “Exhibit C”.

Voluntary Network Services:

Please note that there is a voluntary Utilization Program for Prescription Drugs, Durable Medical Equipment over $50 or rental for more than 30 days, Diagnostic Imaging including Magnetic Resonance Imaging (MRI), Computer Assisted Topography (CAT) and Electro diagnostic Testing listed in 11:3-4.5 (b) 1-3, except when performed by the treating physician. If an insured utilizes a conveniently located network provider for these services/tests, 30% co-pay ($10 for prescription drugs) will be waived. Hoover Rehabilitation Services, Inc. is contracted with ALTA SERVICES, LLC, dba CHN Solutions for voluntary network services. Information regarding the availability of network providers can be found at http://www.chnnetwork.com/volnets/ or by calling Hoover Rehabilitation Services, Inc. at 1-877-704-4440.

Independent Medical Evaluations:

In the event that a patient is requested to attend an Independent Medical Evaluation (IME), the Provider, the Patient and Legal Representative (if applicable) will be notified of the appointment via correspondence. Repeated unexcused failure to attend the scheduled IMEs may result in a termination of the patient's benefits. If the patient is unable to attend the IME for any reason, he/she must provide at least 48 hours notice to the Nurse Case Coordinator at 1-877-704-4440. If the injured person has 2 or more unexcused failures to attend the scheduled IMEs, the injured person, their representative and all providers treating the injured person for the specified diagnosis (or related diagnosis) will be notified that no further reimbursement will be made for all future treatment, diagnostic testing or DME required for the diagnosis (or related diagnosis) contained in the Attending Physicians Treatment Plan form as a consequence for failure to comply with the plan. Failure to hand carry diagnostic films to the examination as requested will be considered an unexcused failure to attend the IME, and the examination will not be conducted.The independent medical examination will be conducted within 7 days of receipt of the request unless the claimant agrees to extend the time frame. The exam will be conducted in a location convenient to the claimant and conducted by a provider in the same discipline as the treating provider. The claimant will provide the medical records or diagnostic films to the provider conducting the examination at or before the examination.The claimant and their treating provider will be notified of the decision whether to reimburse for further treatment, diagnostic tests, or DME within 3 business days after the examination. If the examining provider prepares a written report concerning the examination, the claimant or their designee is entitled to a copy of the report upon request.

Assignment of Benefits:

Benefits are not assignable except to providers of service (Exhibit D). Any such assignment is not enforceable unless the Provider agrees 1) to be subject to the requirements of our Decision Point Review/Precertification Plan, 2) to hold the insured harmless against penalty co-payments based on your failure to follow our Decision Point Review/Precertification Plan and 3) to submit any dispute to alternate dispute resolution pursuant to N.J.A.C. 11:3-5.
 

“DEAR DR. LETTER”
Hoover Rehabilitation Services, Inc.
c/o (Insurance Co.)
(Address)
(Address) 

Date:        

Via Certified and 1st Class Mail 

RE: Patient Name:

Claim Number:
Date of Injury:
Dear Dr. :
  The patient noted above was involved in a motor vehicle accident (MVA) on. We have been informed that he/she will receive treatment with you. Pursuant to N.J.A.C. 11:3-4, et seq, as amended, you are required to provide us with notification for certain tests you may order, or services you may perform on the patient. As described more fully below, this notification is provided in connection with Decision Point Review and Precertification. Hoover Rehabilitation Services, Inc. has been requested by (Insurance Co. name here) to be the Utilization Review Organization involved with the Decision Point Review/Precertification process. Decision Point Review/ Precertification does not apply until the 10th day following the MVA and does not apply to Emergency Care.

Decision Point Review:

Pursuant to N.J.A.C. 11:3-4, et seq., as amended, the New Jersey Department of Banking and Insurance (Department) has published standard courses of treatment, Care Paths, for soft tissue injuries of the neck and back, collectively referred to as the Identified Injuries. (For a list of Identified Injuries by ICD-9 codes, see Exhibit A.) N.J.A.C. 11:3-4, et seq., as amended also establishes guidelines for the use of certain diagnostic tests. The Care Paths provide that treatment be evaluated at certain intervals called Decision Points. On the Care Paths, Decision Points are represented by hexagonal boxes. At Decision Points, you must provide us information about further treatment you intend to provide (Decision Point Review). In addition, the administration of any test on the list in Exhibit B also requires Decision Point Review regardless of the diagnosis. The Care Paths and accompanying rules are enclosed, but are also available on the Internet on the Department's website at http://www.nj.gov/dobi/aicrapg.htm (scroll down to NJAC 11:3-4 Medical Protocols Rule[Care Paths, Decision Point Review, Precertification]) or by calling Hoover Rehabilitation Services, Inc. at 1-877-704-4440. If you fail to submit requests for Decision Point Reviews, or fail to provide clinically supported findings that support the request, payment of your bills will be subject to a penalty co-pay of 50%, even if the services are determined to be medically necessary.
 

Mandatory Precertification:

If your patient does not have an Identified Injury, you are required to obtain Precertification of all services itemized in Exhibit B. If you fail to precertify such services or fail to submit clinically supported findings to support the request, payment of your bills will be subject to a penalty co-pay of 50%, even if the services are determined to be medically necessary. You are encouraged to maintain communication with Hoover Rehabilitation Services, Inc. on a regular basis as precertification requirements may change. For your convenience, the Hoover Rehabilitation Services, Inc. website, www.hooverinc.com contains Precertification requirements, or, we can be reached at 1-877-704-4440.

Voluntary Precertification:

You are encouraged to participate in a Voluntary Precertification process by providing Hoover Rehabilitation Services, Inc. with a comprehensive treatment plan for both identified and other injuries. Hoover Rehabilitation Services, Inc. will utilize nationally-accepted criteria and the Care Paths to work with you to certify a mutually agreeable course of treatment to include itemized services and a defined treatment period. In consideration for your participation in the Voluntary Precertification process, the bills you submit, when consistent with the precertified services, will be paid without utilization audit. In addition, having an approved treatment plan means that as long as treatment is consistent with the plan, additional notification to Hoover Rehabilitation Services, Inc. at Decision Points is not required. As you continue to participate in the Voluntary Precertification process for subsequent services, payment for precertified services will be made without utilization audit. 
 

How to Submit Decision Point/Precertification Requests:

In order to complete our review, we require that you provide us with any past medical history that is available. We also require the diagnosis, all x-ray and other test results that may have been completed, and documentation of all treatment provided to date. Please indicate any tests or treatment you anticipate over the next 30 days. Enclosed is an “ATTENDING PROVIDER TREATMENT PLAN” form that you must use. Please return this completed form, along with a copy of the most recent/appropriate progress notes, and results of diagnostic tests or studies relative to the requested services or FAX (570-283-1637). If you have any questions regarding your request, you may telephone us at 1-877-704-4440.Our review of Decision Point/Precertification requests and voluntary precertification requests will be completed within three business days of receipt of the necessary information. Notice of certification will be made to your office by telephone and confirmed in writing. If we fail to notify you within three business days, you may continue with the test or treatment until a final determination is communicated to you. In addition, if an independent physical or mental examination is required, treatment may proceed while the exam is being scheduled and the results become available.

Review Outcomes:

·Requested service is certified.
 ·In the event we receive insufficient information that does not support the requested service, an administrative denial will be issued and will continue until we receive documentation sufficient to evaluate the request for the diagnostic test or treatment service. Once we receive sufficient documentation a decision will be communicated to you within 3 days of receipt of the documentation.
·Any denial of reimbursement for further treatment or testing will be made by a physician or dentist.
·In the event that we must amend the requested services (either frequency, duration, intensity or place of service or treatment), your office will be notified by telephone and confirmed in writing and a Hoover Rehabilitation Services, Inc. physician advisor will be available to discuss the case with you.
·In the event we are unable to certify the request, your office will be notified by telephone and confirmed in writing. A Hoover Rehabilitation Services, Inc. physician advisor will be available to discuss the case with you. If the request is for a surgical procedure, we will assist the patient/insured to schedule a second surgical opinion, at the expense of Pennsylvania National Insurance/Founders Insurance Company.
·Pursuant to N.J.A.C. 11:3-4, et seq., as amended and the patient's/Insured's policy:Failure to request decision point review or precertification where required or failure to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested shall result in additional co-payment not to exceed 50% of the eligible charge for medically necessary diagnostic tests, treatments or durable medical goods that were provided between the time of notification to the insurer was required and the time that proper notification is made and the insurer has an opportunity to respond in accordance with its approved decision point review plan.

Reconsideration Process:

If your request does not meet certification criteria, clinical rationale for this determination is available upon request. You are encouraged to utilize Hoover's internal review process for reconsideration by contacting Hoover Rehabilitation Services, Inc. at 1-877-704-4440. Enclosed as “Exhibit C”, is information regarding the Reconsideration and Appeal Process.
 

Voluntary Network Services:

Please note that your patient's policy includes a voluntary Utilization Program for Prescription Drugs, Durable Medical Equipment over $50 or rental for more than 30 days, Diagnostic Imaging including Magnetic Resonance Imaging (MRI), Computer Assisted Tomography (CAT) and Electrodiagnostic Testing listed in 11:3-4.5 (b) 1-3, except when performed by the treating physician. If an insured utilizes a conveniently located network provider for these services/tests, 30% co-pay ($10 for prescription drugs) will be waived. Hoover Rehabilitation Services, Inc. is contracted with ALTA SERVICES, LLC, dba CHN Solutions for voluntary network services. Information regarding the availability of network providers can be found at http://www.chnnetwork.com/volnets/ or by calling Hoover Rehabilitation Services, Inc. at 1-877-704-4440.
 

Independent Medical Evaluations:

In the event that your patient is requested to attend an Independent Medical Evaluation (IME), you, your patient and legal representative (if applicable) will be notified of the appointment via correspondence. Repeated unexcused failure to attend the scheduled IMEs may result in a termination of your patient's benefits. If the patient is unable to attend the IME for any reason, they must provide at least 48 hours notice to the Nurse Case Coordinator at 1-877-704-4440. If the injured person has 2 or more unexcused failures to attend the scheduled IMEs, the injured person, their representative and all providers treating the injured person for the specified diagnosis (or related diagnosis) will be notified that no further reimbursement will be made for all future treatment, diagnostic testing or DME required for the diagnosis (or related diagnosis) contained in the Attending Physicians Treatment Plan form as a consequence for failure to comply with the plan. Failure to hand carry diagnostic films to the examination as requested will be considered an unexcused failure to attend the IME, and the examination will not be conducted. 

The independent medical examination will be conducted within 7 days of receipt of the request unless the claimant agrees to extend the time frame. The exam will be conducted in a location convenient to the claimant and conducted by a provider in the same discipline as the treating provider.

The claimant will provide the medical records or diagnostic films to the provider conducting the examination at or before the examination. The claimant and their treating provider will be notified of the decision whether to reimburse for further treatment, diagnostic tests, or DME within 3 business days after the examination. If the examining provider prepares a written report concerning the examination, the claimant or their designee is entitled to a copy of the report upon request.

Assignment of Benefits:

Benefits are not assignable except to providers of service. Any such assignment is not enforceable unless you agree 1) to be subject to the requirements of our Decision Point Review/Precertification Plan, 2) to hold the insured harmless against penalty co-payments based on your failure to follow our Decision Point Review/Precertification Plan and 3) to submit any dispute to alternate dispute resolution pursuant to N.J.A.C. 11:3-5. 

The staff at Hoover Rehabilitation Services, Inc. remains available to you and your patient, to answer questions and assist with the precertification process. 

Thank you for your continued cooperation.

Sincerely,

 

HOOVER REHABILITATION SERVICES, INC.
Precertification Department

Nurse Case Coordinator

Enclosures:
Exhibits A, B, C, & D
Attending Physicians Treatment Plan Form
Care Paths
Flow Chart

EXHIBIT A

 

Hoover Rehabilitation Services, Inc. EXHIBIT A Identified Injuries

 

722.0 Displacement of cervical intervertebral disc without myelopathy
722.1 Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.10 Displacement of lumbar intervertebral disc without myelopathy
722.11.1 Displacement of thoracic intervertebral disc without myelopathy
722.2 Displacement of intervertebral disc, site unspecified, without myelopathy
722.70 Intervertebral disc disorder with myelopathy, unspecified region
722.71 Intervertebral disc disorder with myelopathy, cervical region
722.72 Intervertebral disc disorder with myelopathy, thoracic region
722.73 Intervertebral disc disorder with myelopathy, lumbar region
728.0 Disorders of muscle, ligament and fascia
728.85 Spasm of muscle
739.0 Non-allopathic lesions-not elsewhere classified
739.1.1.1 Somatic dysfunction of cervical region
739.1.1.2 Somatic dysfunction of thoracic region
739.3 Somatic dysfunction of lumbar region
739.4 Somatic dysfunction of sacral region
739.8 Somatic dysfunction of rib cage
846.0 Sprains and strains of sacroiliac region
846.1 Sprains and strains of lumbosacral (joint)(ligament)
846.2 Sprains and strains of sacrospinatus (ligament)
846.3 Sprains and strains of sacrotuberous region
846.8 Sprains and strains of other specified sites of sacroiliac region
846.9 Sprains and strains, unspecified site of sacroiliac region
847.0 Sprains and strains of neck
847.1 Sprains and strains, thoracic
847.2 Sprains and strains, lumbar
847.3 Sprains and strains, sacrum
847.4 Sprains and strains, coccyx
847.9 Sprains and strains of back, unspecified site
922.3 Contusion of back
922.31 Contusion of back, excludes interscapular region
922.33 Contusion of back, interscapular region
953.0 Injury to cervical root
953.2 Injury to lumbar root
953.3 Injury to sacral root

Glossary of Terms

 

TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK - CARE PATHS
EXHIBIT 1 -Glossary of Terms
Acute Disease - a disease with rapid onset and short course to recovery. Not chronic.
Care Path - a recommended extensive course of care based on professionally recognized standards.
Case Management - a method of coordinating the provision of healthcare to persons injured in automobile accidents, with the goal of ensuring continuity and quality of care and cost effective outcomes. The Case Manager may be a nurse, social worker psychologist, or physician, preferably with certification in case management.
Cauda Equina - a collection of spinal roots that descend from the lower part of the spinal cord. They exist in the lower part of the vertebral canal.
Chronic Disease - a disease with long duration that changes little and progresses slowly. The opposite of acute.
Clinical Evaluation - the evaluation of the symptoms and signs of an injured person by a treating practitioner.
Conservative Therapy - treatment which is not considered aggressive; avoiding the administration of medicine or utilization of invasive procedures until such procedures are clearly indicated.
Contusion - an injury to underlying soft tissues where the skin is not broken. A bruise.
Diagnostic Evaluation - the process of differentiating between two or more diseases with similar signs and symptoms through the use of evaluative procedures such as imaging, laboratory, and physical tests.
Herniation - the protrusion or projection of an organ or other body structure through a defect or natural opening in a covering membrane, muscle, or bone.
Independent Consultative Opinion - physical examination by a physician of similar specialty to the injured person's treating practitioner to provide a second medical opinion. The independent physician may support, refute, or provide alternatives to the current diagnosis and treatment plans.
Non-Compliant - a patient who willfully chooses not to participate in the treatment plan agreed upon by the patient and his/her healthcare provider and does not have secondary issues such as lack of transportation, pre-existing conditions or comorbidities.
PT - Physical Therapy - the evaluation, assessment, and treatment of dysfunction caused by injuries to the soft tissue and muscles/skeleton . Treatment shall consist of therapeutic exercises, education and other modalities, such as the therapeutic use of heat, light, water, electricity, massage and non-ionizing radiation, and procedures that focus on improving posture, locomotion, strength, endurance, balance coordination, joint mobility, flexibility and an individual's ability to go through the functional activities of daily living (ADLS) and on alleviating pain. PT rendered to persons injured in automobile accidents must be provided by a person whose scope of licensure includes physical therapy.
Radicular - pertaining to a root (such as a nerve root) disorder.
Radiculopathy - a disorder of a nerve root.
Sign - an objective manifestation, usually indicative of a disease or disorder. Signs can be observed by the clinician, as opposed to symptoms which are perceived only by the affected individual.
Soft Tissue Injury - injuries sustained to the muscle, skin, connective tissue.
Spine - the vertebral column. Spinal Shock - an acute condition resulting from spinal cord severance. Characterized by a total sensory loss and loss of reflexes below the level of injury and flaccid paralysis.
Sprain - an injury at a joint where a ligament is stretched or torn.
Strain - an injury caused by the over-stretching or tearing of a muscle or tendon. In its most severe form, the muscle ruptures.
Symptom - a subjective manifestation, usually indicative of a disease or disorder. Symptoms are experienced only by the affected individual, as opposed to signs which can be observed by others.
Treatment Plan - specific medical, surgical, chiropractic, acupuncture, or psychiatric and psychological procedures used to improve the signs or symptoms associated with injuries sustained in automobile accidents, e.g., physical therapy, surgery, administration of medications, etc. 

 

EXHIBIT B

Diagnostic Tests that are subject to Decision Point Review (all diagnosis)

1. Brain audio evoked potentials (BAEP),
2. Brain evoked potentials (BEP),
3. Computer assisted tomograms (CT, CAT scan),
4. Dynatron/cybex station/cybex studies,
5. Electroencephalogram (EEG),
6. H-reflex studies,
7. Magnetic resonance imaging (MRI),
8. Needle electromyography (EMG),
9. Nerve conduction velocity (NCV),
10. Somatosensory evoked potential (SSEP),
11. Sonogram/ultrasound,
12. Videofluroscopy,
13. Visual evoked potential (VEP)
14. Brain Mapping
15. Thermography and ThermogramsServices that require Precertification 

1. Non-emergency inpatient and outpatient hospital care,
2. Non-emergency surgical procedures,
3. Durable medical equipment (including orthotics and prosthetics), costing greater than $50, or rental greater than 30 days,
4. Extended care and rehabilitation,
5. Home health care,
6. Outpatient psychological/psychiatric testing and/or services,
7. All physical, occupational, speech, cognitive, or other restorative therapy, or body part manipulation except that provided for Identified Injuries in accordance with Decision Point Review; and
8. All pain management services except that provided for Identified Injuries in accordance with Decision Point Review,
9. Non-emergency dental restoration.

 

EXHIBIT C

Reconsideration Process HOOVER REHABILITATION SERVICES, INC.
1. When Hoover is unable to certify, or renders a determination not to certify an admission, hospital stay, treatment plan, diagnostic test, or other service the attending or ordering provider:
·Will be notified by telephone of the determination within 3 days, which will be confirmed in writing,
·May request the clinical criteria utilized to make the determination,
·Will have the opportunity to request reconsideration by the physician advisor who made the initial determination.

2. The attending or ordering provider may initiate the reconsideration request by telephoning Hoover Rehabilitation Services, Inc. at 1-877-704-4440. In addition, the provider may be required to submit additional information to support the reconsideration request.

3. The reconsideration will occur within one (1) business day of the receipt of the request. It will be conducted between the attending physician and other ordering provider and the Hoover Physician Advisor who made the initial determination. Should the original Physician Advisor not be available within one (1) working day, Hoover will designate another Physician Advisor to complete the reconsideration. The Hoover Rehabilitation Services Inc. Medical Director is available to discuss the decision to deny with the treating/ordering provider. The ordering provider should call 1-877-704-4440 to make arrangements for this discussion. The decision will be communicated to the provider, the claimant and attorney, via facsimile, certified and regular mail within one day.

4. When, during the course of generating a review determination, it becomes necessary for the Hoover Physician Advisor to refer the case to a specialist-consultant on Hoover's Medical Advisory Board, the specialist-consultant (or one of like specialty) will be available to participate in the reconsideration process. Provider Appeal Process When reconsideration does not resolve a difference of opinion, the attending or ordering provider may submit the case for appeal through the Personal Injury Protection Dispute Resolution process. Hoover will inform the physician or other ordering provider of their right to initiate an appeal and the procedure to do so when the review determination has been made. The appeal may be made to a state-certified MRO through the National Arbitration Forum, at 732-231-6100. Forms, rules and procedures are available on the web at http://www.arb-forum.com/nj/news.asp.

EXHIBIT D
(Insurance Company): Assignment of Benefits Payment of Benefits
1. The Insurance Company may, at their option, pay any medical expense benefits or essential services benefits to the:
a. “Insured,” or
b. Person or organization providing products or services for such benefits.

These benefits shall not be assignable except to providers of service benefits. Any attempt to assign benefits to a party who is not a provider of service benefits shall be null and void and shall not be honored. If so assigned, all requirements, duties and conditions of the Policy, including but not limited to Precertification, Decision Point Reviews, exclusions, deductibles, co-payments and duties of cooperation following an accident or loss, shall remain in effect. If a valid assignment is made by an Insured and accepted by the provider of the assigned service benefits, the provider shall 1) agree to be subject to the requirements of our Decision Point Review /Precertification Plan, 2) indemnify and hold harmless the Insured against any penalty co-payments caused by the provider's failure to comply with the terms of our Decision Point Review/Precertification Plan and 3) submit any dispute to alternate dispute resolution.

 

HOME - Employees Only - Our Mission - FAQ's - A Message from Our President - E-mail Us
Office Locations - Service Requests - Job Opportunities - What We Offer - Resource Center - Other Services

Hoover Rehabilitation Services Inc. Copyright © 2004. Hoover Rehabilitation Services Inc. All rights Reserved. Privacy Policy
Site Best viewed with Internet Explorer v. 6.0 or later and Flash Player 7.0 Click Here to download Macromedia Flash Player.
Site created by Rutan Interactive for CX Media