New Jersey Arbitration

img

Welcome to the C.32 Out-of-Network Arbitration (OON) and Program for Independent Claims Payment Arbitration (PICPA) Application Website. These New Jersey Department of Banking and Insurance programs are operated under contract by Maximus, Inc., a professional and technical services firm that provides support to critical federal, local, state, and foreign government initiatives.

Users of this site

img

This site may be used by provider, provider representative or carrier. For member related arbitration please contact Maximus at njarbitrations@maximus.com

Dispute Resolution Pathways

img

There are two processes for resolving Out-of-Network claim disputes via the Maximus Federal Portal

img

C. 32 Out-of-Network Arbitration (OON) applies where:

  • On the date of service the covered person was enrolled in an insured health benefits plan issued in New Jersey, a self-funded health benefits plan that opts in to C. 32 OON Arbitration (as stated on member's ID card), the State Health Benefits Plan, the School Employees Health Benefits Plan, or a Multiple Employer Welfare Arrangement, and
    • Services are rendered by an out-of-network provider on or after August 30, 2018 on an inadvertent, emergency or urgent basis in New Jersey by a provider who is licensed or certified in New Jersey;
    • The carrier has determined the out-of-network provider's billed charges to be excessive and negotiations between the out-of-network provider and the carrier in the 60-day period following communication of said determination have not resulted in a settlement; and
    • The difference between the carrier's final offer and the out-of-network provider's final offer is $1,000 or more.
  • The member was covered by a self-funded health benefits plan that did not opt in to C. 32 OON arbitration on the date of service, and
    • Services are rendered by an out-of-network provider on or after August 30, 2018 on an inadvertent, emergency or urgent basis;
    • The out-of-network provider bills the member; and
    • . The member and the provider do not resolve the payment dispute within 60 days after the bill is sent.

img

Program for Independent Claims Payment Arbitration (PICPA) applies where:

  • Services are rendered:
    • by an out-of-network provider on a voluntary basis, i.e. not on an inadvertent, emergency or urgent basis;
    • by an out-of-network provider on an inadvertent, emergency or urgent basis outside of New Jersey or prior to August 30, 2018; or
    • by a network provider;
  • On the date of service, the covered person was covered by an insured health benefits plan issued in New Jersey;
  • The provider has completed an internal payment appeal; and
  • The amount in dispute is $1,000 or higher.

Contact Us

Maximus, Inc.
Attn: New Jersey Provider Appeals
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

Email: njarbitrations@maximus.com

PHONE: (585) 348-3116
FAX: (585) 869-3388