New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 3 - AUTOMOBILE INSURANCE
Subchapter 4 - PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS
Section 11:3-4.9 - Assignment of benefits; public information

Universal Citation: NJ Admin Code 11:3-4.9

Current through Register Vol. 56, No. 6, March 18, 2024

(a) Pursuant to 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, 47:1A-1 et seq. The Department shall notify the insurer prior to responding to any public record request for proprietary information.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.