PIP for Medical Providers

The majority of automobile insurance carriers licensed to do business in New Jersey include a clause in their policy which dictates that all disputes regarding Personal Injury Protection (PIP) benefits must be litigated under the auspices of Forthright Solutions. Forthright has been selected by the State of New Jersey to administer PIP arbitrations under the State’s Automobile Insurance Cost Reduction Act. Once a Demand for arbitration is filed, Dispute Resolution Professionals (DRPs), licensed attorneys who have years of experience in PIP litigation, are assigned by Forthright to conduct the litigation. It is important to note that the decisions of the DRPs are binding. Our lawyers have successfully represented Medical Providers, as well as, Individual Insureds, since the inception of this arbitration process.

Philip S. Burnham and his staff have successfully litigated thousands of PIP arbitrations on behalf of Medical Providers and Suppliers since 1993. Whether filing under an assignment of benefits for

a Medical Provider, or directly on behalf of the Individual Insured, our vast experience has achieved an great success rate, which ultimately results in extremely satisfied clients.

Comprehensive PIP Services

New Jersey’s No-Fault Insurance PIP benefits can be confusing and frustrating. Calls from unhappy clients, whose benefits have been cut off, and calls from providers who have not been properly compensated, can be a drag on staff - monopolizing valuable time and money. The Burnham Law Group is dedicated to helping you, your clients and your doctors navigate the complex system of PIP litigation at absolutely no cost to you – EVER.

When the Burnham Law Group represents you in your PIP Dispute Resolution, all costs connected with the initiation and resolution of the PIP litigation will be advanced by our law firm. There will NEVER be any costs or legal fee demanded from you, your clients or doctors regardless of the outcome of the PIP Dispute Resolution.

Pre-certification of Medical Treatment: Patients, doctors and other medical providers must pre-certify certain types of medical treatment for patients injured in automobile accidents. Failure to pre-certify or properly appeal the denial of pre-certification may result in the denial of payment. Moreover, insurance companies will frequently contest the medical necessity of treatment, as well as, the need for diagnostic tests, such as MRIs and EMG/NCV studies.

Our lawyers will help doctors and other providers navigate this complex process, which will result in fair and quick compensation for their services.

  • Over 98% Success Rate
  • No Costs
  • No Risk
  • Immediate Turnaround
  • Unique Process
  • Value Added Services

Who We Represent

  • Medical Providers
  • Chiropractors
  • Neurologists
  • Imaging Centers
  • Pain Management Specialists
  • Orthopedic Specialists
  • Hospitals
  • Surgeons
  • Surgery Centers
  • Dentists
  • Anesthesiologists
  • Diagnostic Facilities
  • Physical Therapists
  • Medical Supply Companies
  • Personal Injury Law Firms
  • Individual Insureds

Important PIP Notices – UPDATE

The New Jersey Department of Banking and Insurance (DOBI) recently adopted new rules regarding the requirements for Internal Appeals Procedures in Personal Injury Protection Benefits cases. The new appeals process went into effect on April 17, 2017. In addition, Forthright is now requiring us to submit copies of all appeals at the time of filing every arbitration; therefore, it is imperative that all appeals be provided to us or we will be unable to file the arbitrations until we receive them.

The insurance companies have been updating their Decision Point Review Plans to reflect these changes to the appeals process. We have organized this information in the attached chart summarizing the new requirements for each insurance company. Please make use of this convenient tool in preparing your appeals in compliance with the new rules.

Please be aware that several insurance companies are now requiring you to wait for them to respond to the pre-service appeal before performing the requested treatment on the patient. Failure to do so runs the risk of invalidating the assignment of benefits. These companies are highlighted in red on the attached chart.

Other companies (highlighted in orange on the attached chart) are now requiring that the pre-service appeal be submitted prior to performing the requested treatment on the patient. This is less of a delay than waiting for the response, but is still problematic.

In addition, many insurance companies (highlighted in yellow on the attached chart), are now requiring providers to submit the pre-service appeal within 30 days of the denial of precertification. Only appeals submitted within that 30 day window will be considered valid; appeals submitted after this time frame will be considered new precertification requests, not appeals.

As always, we at the Burnham Law Group are committed to assisting our clients throughout the arbitration process. If you would like us to review your new appeals or narratives and provide constructive feedback, we are happy to do so. If you have any questions about the new appeal process or how to comply with the new rules, please reach out to us for guidance.

PIP Benefit FAQ

As we previously informed you, the New Jersey Department of Banking and Insurance (DOBI) recently adopted new rules regarding the requirements for Internal Appeals Procedures in Personal Injury Protection Benefits cases. The new appeals process went into effect on April 17, 2017. Please use the new Uniform Pre- and Post-Service Appeals forms we have sent you from now on.

The DOBI just updated their FAQ page in response to questions they received regarding the implementation of these new rules.

Q: How will the April 17, 2017 operative date of the new internal appeals rule be implemented?

A: The Department believes that the rule should apply to new pre-service and post-service appeals that are submitted on or after April 17, 2017. Appeals that are already in progress, including second level appeals, would continue under the insurer's old system. This would result in all appeals being handled consistently in accordance with the regulation from 04/17/2017 going forward. This will be less confusing for providers and insurers and is consistent with how the effective date of other changes to DPR plans have been handled by the Department.

In light of this guidance provided by DOBI, we recommend that you still complete a second level appeal under the insurer’s old rules for any accounts that would have required one prior to the April 17, 2017 effective date of the new rules. For any new appeals, use the new Uniform Appeal forms in compliance with the new rules.

The insurance companies are in the process of updating their Decision Point Review Plans to reflect these changes to the appeals process. Farmers Insurance Company’s updated Plan (attached, see page 7) states that providers may not perform any treatment for which pre-certification is denied until the Pre-Service Appeal is completed and the appeal decision has been received by the provider or the assignment of benefits is void. So far, this seems to be the only insurance company that has required this, but we will continue to update you as more information becomes available.

As always, we at the Burnham Law Group are committed to assisting our clients throughout the arbitration process. If you have any questions about the new appeal process or how to comply with the new rules, please reach out to us for guidance.

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