Maximus Federal Portal

N.J.S.A. 26:2SS-1 to -20 permits health care providers, carriers and, in certain instances, covered persons to apply for arbitration when they cannot agree on the appropriate reimbursement for health care services rendered by an out-of-network health care provider on an inadvertent, emergency or urgent basis.

Use this form to request OON arbitration only if:

• The covered person to whom health care services were rendered was covered under a network-based health benefits plan that was issued by a carrier in New Jersey;
• The health care service was rendered in New Jersey by a New Jersey licensed facility or practitioner;
• The health care provider that rendered the health care services is not in the network of the covered person’s health benefits plan;
• The covered person received out-of-network services from: (a) an out-of-network health care provider at an in-network health care facility on an inadvertent basis; (b) an out-of-network health care facility and/or practitioner on an emergency or urgent basis; or, (c) an out-of-network bio-analytical laboratory that performed a test that was ordered by an in-network health care provider and the covered person was not provided the opportunity to select an in-network bio-analytical laboratory; and
• There is no dispute as to whether the health care services provided were Medically Necessary, cosmetic, experimental or investigational, or warranted an in-plan exception and the services are otherwise covered under the terms of the covered person’s health benefits plan.

This application for arbitration can be submitted by a health care provider, by the carrier (which, for purposes of this process includes the SHBP, the SEHBP, a MEWA, and any other payor providing a self-funded health benefits plan that opts into arbitration), or by a person covered by a self-funded health benefits plan in New Jersey that did not opt to participate in arbitration. However, a health benefits plan does not include coverage through Medicare or Medicaid.

Self-funded Plans

Employers that self-fund may elect to use the OON Arbitration system. If a self-funded plan chooses to use the OON Arbitration System, the plan will be bound by the decision of the arbitrator. Persons covered by self-funded plans that do not opt into OON arbitration and the providers who treat such persons can still request OON arbitration but the arbitrator’s decision will not be binding on the self-funded plan and will not be based on the final offers of the provider and the self-funded plan. The arbitrator’s decision will be binding on the covered person and the provider.

Release of Medical Records

If a health care provider needs to provide medical records to support a claim in arbitration, the health care provider must submit 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. A covered person does not need to submit this form. The form is available at https://www.nj.gov/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 OON 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 per case
• Arbitration Fee -- $150.00 per case

Initial Review and Arbitration Review

After receiving 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 Initiating Party, the Responding Party, or both. Maximus will make such requests to the appropriate Party in writing, and the Party will have ten (10) calendar days to respond with the requested information in writing. The Parties will have to submit the requested information via the portal.

Individuals seeking arbitration covered by a self-funded plan that did not opt in to C.32 OON Arbitration must submit an application directly to Maximus instead of completing the online application. Refer to Maximus contact information above to submit application and supporting documentation. The C.32 OON application is available at the bottom of this page.

OON Bulletin

https://www.state.nj.us/dobi/bulletins/blt18_14.pdf

Other Issues

If dissatisfied with a claims determination, but the situation does not meet the requirements for a Chapter 32 Independent Arbitration, there are other processes available for health care providers or consumers to use. See https://www.nj.gov/dobi/division_insurance/managedcare/index.htm .

Questions

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 njarbitration@maximus.com. Please note that Maximus will not accept verbal arguments for inclusion in the case record.

Eligibility for the PICPA

The PICPA is designed to consider only a segment of claims disputes. A claim is eligible for arbitration only if:

• 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;
• Medicare;
• 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.

Application Process

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.

Questions

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 njarbitration@maximus.com. Please note that Maximus will not accept verbal arguments for inclusion in the case record.