Eligibility for the PICPA
Program for Independent Claims Payment Arbitration (PICPA) Application
The PICPA is designed to consider only a segment of claims disputes. A claim is eligible for arbitration
The claim was payable by an insurance company, health service corporation, hospital service corporation, medical service
corporation, health maintenance organization, prepaid prescription service organization, or its agent,
including an organized delivery system (ODS) or a third party administrator (TPA), pursuant to the
terms of a health benefits plan issued in this State. Disputes of claims payable by the following
are not eligible for consideration by the PICPA:
A self-funded entity;
The State Health Benefits Program;
Medicaid (other than Medicaid managed care claims);
The Federal Employees Health Benefits Program;
A dental service corporation;
A dental plan organization (DPO);
Any carrier paying claims in accordance with personal injury protection, or bodily injury protection provisions of an automobile
policy, worker's compensation policies, or similar such provisions of other liability policies;
The claim arises from health care services rendered on or after July 11, 2006;
The health care provider appealed the denied or disputed claim to the payer within 90 days of the claim payment determination
by submitting the Health Care Provider Application to Appeal a Claims Determination form to access
the internal claims appeal process; The payer's internal HCAPPA claim appeal process was completed,
OR the payer failed to comply with the processing and review timeframes with respect to the claim,
and the health care provider has documentation supporting that contention;
The amount in dispute is $1,000 or more;
When aggregating claims (for the purpose of reaching the $1,000 threshold), a health care provider aggregates claims by carrier
and covered person OR by carrier and CPT code; and
The health care provider submits the application for arbitration timely with the appropriate fees.
The NJ Department of Banking and Insurance has set forth the following deadlines for timely submission
of applications for arbitration, and rendering of arbitration decisions:
- If the claims appeals was completed, or should have been completed, on or after August 1, 2007, then the application for
arbitration must be completed and fees submitted within 90 days following the date the claims appeal
was completed, or should have been completed by the payer, and Maximus will render a decision within
30 calendar days following receipt of application, documentation and fees.
Through this site, health care providers and carriers may submit an Application for Arbitration online, and attach supporting
documentation if the information is in an electronic format, including scanned documents. To complete
an application, the initiating party must first Register by clicking here
. (After initial registration, the user will receive an email with login details within 48 business hours. You may not login
to create cases until you receive your login details from Maximus.)
- All information related to your internal claims appeal, including a copy of the Health Care Provider Application to Appeal
a Claims Determination, and the payer's decision, if any.
- All relevant medical records and billing records (HCFA 1500, UB92s).
- All relevant correspondence between the health care provider and payer.
- Although not required, a completed Consent to Representation in Appeals of Utilization Management
Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration
of Claims (Consent) should be submitted if the party requesting arbitration wants medical records reviewed
by the arbitrator.*
* While a (Consent) is not required for the PICPA process, a missing or incomplete member consent may impact the information
available to the arbitrator from the medical record which, in turn, may affect the arbitrator's decision.
The Consent form is available on-line at the Departments website at www.state.nj.us/dobi/chap352/352consentform.doc
Fees and Payment
The application and arbitration process is composed of two parts, and there is a separate fee for each part of the process.
The Initial Review determines whether your request qualifies for actual arbitration based on the information
submitted. If the request qualifies, then the matter will go to arbitration for a decision on the case.
However, to complete your application, you must remit payment for the Initial Review fee.
Upon filing the PICPA arbitration request here on this site, you will be prompted to submit payment electronically (convenience
fee applies to electronic payments) or you may send two checks (or money orders) made payable to Maximus
at the address below. The separate checks should be made for amounts consistent with the following:
Initial Review Fee -- $72.50 for every claim submitted with a disputed amount of $1,000 or more OR $72.50 for every $1,000
in dispute for aggregated claims of less than $1,000 each.
Arbitration Fee -- $150.00 for every claim submitted with a disputed amount of $1,000 or more OR $150.00 for every $1,000
in dispute for aggregated claims of less than $1,000 each.
Alert: Your case may be disaggregated. Maximus is permitted under the PICPA process to disaggregate cases when appropriate.
Cases involving multiple lines of code and more than $2,000 may be disaggregated. You will be notified
if your case is disaggregated. Please be aware that additional initial review fees and arbitration fees
will be required if your case is disaggregated.
Initial Review and Arbitration Review
After receiving the Initiating Party’s completed application, Maximus will contact the Responding Party for a response, documentation,
and payment of its portion of the fees. Maximus will review the application and all documentation, and
will contact the Parties as to whether the request has been accepted for arbitration.
In some cases, Maximus may need to request additional information from the party initiating arbitration, the responding party,
or both. Maximus will make such requests to the appropriate party in writing, and the party will have
ten days to respond with the requested information in writing. Health care providers and Payers will
have to submit the requested information via the portal.
Reviews will be based solely on the submitted documentation. Reviews will be performed by independent and impartial health
claims professionals with at least five years of claims processing experience. Maximus will forward the
written results of the Arbitration to the initiating party, responding party, and the New Jersey Department
of Banking and Insurance within 30 calendar days following receipt of the documentation necessary for
making a decision.
If you have any problems completing your application or you have questions regarding the arbitration process and other administrative
matters, please contact Maximus via email at email@example.com. Please note that Maximus will not accept
verbal arguments for inclusion in the case record.