New Jersey Personal Injury Protection Claims Guide

GEICO Personal Injury Protection (PIP) Notice

Buffalo/New Jersey Claims, PO Box 9515
Fredericksburg, VA 22403-9595

Personal Injury Protection (PIP) is the portion of the auto policy that provides coverage for medical expenses. These medical expenses are subject to policy limits, deductibles, co-payments and any applicable medical fee schedules. Additionally, these medical expenses must be for services that are deemed medically necessary and causally related to the motor vehicle accident. With the adoption of the Automobile Cost Reduction Act of 1998, several important changes have been made in the way a claim is processed.

Additional information regarding Decision Point Review/Pre-Certification can be accessed on the Internet at the New Jersey Department of Banking and Insurances website at http://www.nj.gov/dobi//filings.htm.

Premier Prizm Solutions LLC has been selected by to implement their plan as required by the Automobile Cost Reduction Act. Premier Prizm will review treatment plan requests for Decision Point Review/Pre-Certification, perform Medical Bill Repricing and Audits of provider bills, coordinate Independent Medical Exams and Peer Reviews, and provide Case Management Services.

If certain medically necessary services are performed without notifying or Premier Prizm, a penalty/co-payment may be applied. Medical care rendered in the first 10 days following the covered loss or any care received during an emergency situation is not subject to Decision Point Review/Pre-certification.

Mailing Instructions:

All Decision Point Review, pre-certification and internal appeals related documents are to be submitted to:

Premier Prizm Solutions, LLC
10 East Stow Road
Suite 100
Marlton, New Jersey 08053
Phone Number: 856-596-5600
Fax Number: 856-596-6300
Email Address AICRA@PremierPrizm.com

All other mail is to be submitted to:

Submission of Treatment Plan Requests for Decision Point Review/Pre-Certification

Please bring the “Attending Provider Treatment Plan” form to your treating provider for completion. This completed form along with any applicable medical documentation should be forwarded to Premier Prizm by fax (856-596-6300), or mail (10 East Stow Road, Suite 100 Marlton, NJ 08053) or email to TreatmentRequests@PremierPrizm.com. This form can be accessed on Premier Prizm’s web site at www.PremierPrizm.com. Any questions regarding your treatment request can be directed to Premier Prizm at 856-596-5600 during regular business hours of Monday through Friday 8:00 AM to 5:00 PM, EST except for Federally Declared Holidays.

Decision Point Review

Pursuant to N.J.A.C. 11:3-4, the New Jersey Department of Banking and Insurance has published standard courses of treatment, known as Care Paths, for soft tissue injuries, collectively referred to as Identified Injuries. Additionally, guidelines for certain diagnostic tests have been established by the New Jersey Department of Banking and Insurance according to N.J.A.C. 11:3-4. Decision Points are intervals within the Care Paths where treatment can be evaluated for a decision about the continuation or choice of further treatment. At Decision Points, the eligible injured person or the health care provider must provide Premier Prizm with information regarding further treatment the health care provider intends to provide.

In accordance with N.J.A.C. 11:3-4.5, the administration of any of the following diagnostic tests is subject to Decision Point Review, regardless of diagnosis.

Diagnostic Tests which are subject to Decision Point Review according to N.J.A.C. 11:3-4.5

1. Needle Electromyography (EMG)
2. Somatosensory Evoked Potential (SSEP)
3. Visual Evoked Potential (VEP)
4. Brain Audio Evoked Potential (BAEP)
5. Brain Evoked Potentials (BEP)
6. Nerve Conduction Velocity (NCV)
7. H-Reflex Studies
8. Electroencephalogram (EEG)
9. Videofluoroscopy
10. Magnetic Resonance Imaging (MRI)
11. Computer Assisted Tomograms (CT, CAT Scan)
12. Dynatron/Cybex Station/Cybex Studies
13. Sonogram/Ultrasound
14. Brain Mapping
15. Thermography/Thermograms

Pre-Certification

Pursuant to N.J.A.C. 11:3-4.7, the New Jersey Department of Banking and Insurance, Premier Prizm’s Pre-Certification Plan requires pre-authorization of certain treatment/diagnostic tests or services. Failure to pre-certify these services may result in penalties/co-payments even if services are deemed medically necessary.

If the eligible injured person does not have an Identified Injury, your treating provider is required to obtain pre-certification of treatment, diagnostic tests, services, prescriptions, durable medical equipment or other potentially covered expenses as noted below:

1. Non-emergency inpatient and outpatient hospital care
2. Non-emergency surgical procedures
3. Extended Care Rehabilitation Facilities
4. Outpatient care for soft-tissue/disc injuries of the person’s neck, back and related structures not included within the diagnoses covered by the Care Paths.
5. Physical, Occupational, Speech, Cognitive, Rehabilitation or other restorative therapy or therapeutic or body part manipulation except as provided for identified injuries in accordance with Decision Point Review.
6. Outpatient psychological/psychiatric treatment/testing or other services
7. All pain management services except as provided for identified injuries in accordance with Decision Point Review
8. Home Health Care
9. Acupuncture
10. Durable Medical Equipment (including orthotics or prosthetics) with a cost or monthly rental in excess of $100.00 or rental in excess of 30 days
11. Non-Emergency Dental Restorations
12. Temporomandibular disorder; any oral facial syndrome
13. Non-medical products, devices, services and activities, and associated supplies, not exclusively used for medical purposes or as durable medical goods, with an aggregate cost or monthly rental in excess of $100.00 or rental in excess of 30 days, including but not limited too:
    1. Vehicles
    2. Modifications to vehicles
    3. Durable goods
    4. Furnishings
    5. Improvements or modifications to real or personal property
    6. Fixtures
    7. Spa/gym memberships
    8. Recreational activities and trips
    9. Leisure activities and trips

Decision Point Review Pre-Certification Process

On behalf of Geico General Insurance Company, Premier Prizm will review all treatment plan requests and medical documentation submitted. A decision will be rendered within three business days of receipt of a completed "Attending Provider Treatment Plan" form request with supporting medical documentation. If additional information is requested, the decision will be rendered within three days of our receipt of the additional information. In the event that Geico General Insurance Company or Premier Prizm does not receive sufficient medical information accompanying the request for treatment, diagnostic tests or services to make a decision, an administrative denial will be rendered, until such information is received. If a decision is not rendered within three business days of receipt of an “Attending Provider Treatment Plan” form, your treating health care provider may render medically necessary treatment until a decision is rendered.

Please note that the denial of Decision Point Review and Pre-certification requests on the basis of medical necessity shall be the determination of a physician. In the case of treatment prescribed by a dentist, the denial shall be by a dentist.

Voluntary Pre-Certification

We encourage you to participate in a voluntary pre-certification process by bringing a treatment plan request form to your provider or have them contact us for all services requested. Premier Prizm will utilize nationally accepted criteria to authorize a mutually agreeable course of treatment. In consideration for your participation in this voluntary pre-certification process, the bills your provider submits, when consistent with the agreed plan, will not be subject to review or audit as long as they are in accordance with the policy limits, deductibles, and any applicable PIP fee schedule.

Independent Medical Examinations

Premier Prizm or Geico General Insurance Company may request an Independent Medical Examination. At times, this examination may be necessary to reach a decision in response to the treatment plan request by the treating provider.

Premier Prizm will notify you or your designee and the treating provider of the scheduled physical or mental examination and of the consequences for unexcused failure to appear at two or more appointments.

Voluntary Network Services

Premier Prizm has established a network of approved vendors for diagnostic imaging studies for all MRI’s and CAT Scans, durable medical equipment with a cost or monthly rental over $100.00, prescription drugs and all electrodiagnostic testing, listed in N.J.A.C 11:3-4.5(b) 1-3, (unless performed in conjunction with a needle EMG by your treating provider).

Penalty Notification: Failure to submit request for Decision Point Review or Pre-Certification where required, or failure to submit clinically supported findings that support the treatment, diagnostic testing, or durable medical goods requested will result in a co-payment of 50%.

Assignment of Benefits: Please read the Assignment of PIP Benefits section in your policy carefully. All assignments are subject to all requirements, duties and conditions of the policy.

Internal Appeal Process

The Internal Appeal Process shall be utilized before filing arbitration. All appeals concerning a decision related to a treatment request must be submitted in writing and must contain your treating provider's signature and the reason for the appeal.

Appeal Reason

Additional Request / Claim Information