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«Dear»

Personal Injury Protection (PIP) is the portion of the auto policy that provides coverage for medical

expenses. These medical expenses are subject to policy limits, deductibles, co-payment and any

applicable medical fee schedules. Additionally, these medical expenses must be for services that are

deemed medically necessary and causally related to the motor vehicle accident. With the adoption of the

Automobile Insurance Cost Reduction Act of 1998, several important changes have been made in the way

a claim is processed. Additional information regarding Decision Point Review/Pre-Certification can be

treatment plan requests for Decision Point Review/Pre-Certification, perform Medical Bill Repricing and

Audits of provider bills, coordinate Independent Medical Exams and Peer Reviews, and provide Case

Management Services.

If certain medically necessary services are performed without notifying American Commerce Insurance

Company or Prizm a penalty/co-payment may be applied. Medical care rendered in the first 10 days

following the covered loss or any care received during an emergency situation is not subject to Decision

Point Review/Pre-certification. Such treatment (within the first 10 days) shall be subject to retrospective

review as the above provision shall not be construed as to require reimbursement of tests and treatment

that are not medically necessary.

Phone Number: 856-596-5600

Fax Number: 856-596-6300

Email Address [email protected]

Submission of Treatment Plan Requests for Decision Point Review/Pre-Certification

Please complete the attached “Attending Provider Treatment Plan” form and forward with any applicable

medical documentation to Prizm by fax (856-596-6300), or mail (10 East Stow Road Suite 100

Marlton, NJ 08053) or email to TreatmentRequests@Prizmllc.com. This form can be accessed on Prizm’s

web site at www.Prizmllc.com. Any questions regarding your treatment request can be directed to Prizm

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Pursuant to N.J.A.C. 11:3-4, the New Jersey Department of Banking and Insurance has published

standard courses of treatment, known as Care Paths, for soft tissue injuries, collectively referred to as

Identified Injuries. Additionally, guidelines for certain diagnostic tests have been established by the New

Jersey Department of Banking and Insurance according to N.J.A.C. 11:3-4. Decision Points are intervals

within the Care Paths where treatment is evaluated for a decision about the continuation or choice of

further treatment the attending physician provides. At Decision Points, the eligible injured person or the

health care provider must provide Prizm with information regarding further treatment the health care

provider intends to provide.

1. Needle Electromyography (EMG)

2. Somatosensory Evoked Potential (SSEP)

3. Visual Evoked Potential (VEP)

4. Brain Audio Evoked Potential (BAEP)

5. Brain Evoked Potentials (BEP)

6. Nerve Conduction Velocity (NCV)

7. H-Reflex Studies

8. Electroencephalogram (EEG)

9. Videofluroscopy

10. Magnetic Resonance Imaging (MRI)

Pre-Certification

Pursuant to N.J.A.C. 11:3-4.7, the New Jersey Department of Banking and Insurance, Prizm’s Pre-

Certification Plan requires pre-authorization of certain treatment/diagnostic tests or services. Failure to

pre-certify these services may result in penalties/co-payments even if services are deemed medically

necessary. If the eligible injured person does not have an Identified Injury, you as the treating provider are

required to obtain Pre-Certification of treatment, diagnostic tests, services, prescriptions, durable medical

equipment or other potentially covered expenses as noted below:

 All Physical, Occupational, Speech, Cognitive, Rehabilitation or other restorative therapy or

 All Outpatient psychological/psychiatric treatment/testing and/or services;

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 All pain management/pain medicine services except as provided for identified injuries in

 Home Health Care;

 Acupuncture;

 Durable Medical Equipment (including orthotics and prosthetics), with a cost or monthly rental,

 Nutritional Supplements;

 All treatment and testing related to balance disorders;

 Bone Scans;

 Podiatry;

 Prescription Drugs costing more than $100.00;

 All procedures that use an unspecified CPT/CDT, DSM IV, and/or HCPCS code.

Decision Point Review/Pre-Certification Process

receive sufficient medical information accompanying the request for treatment, diagnostic tests or services

to make a decision, an administrative denial will be rendered, until such information is received. If a

decision is not rendered within three (3) business days of receipt of an “Attending Provider Treatment Plan

“ form, you, as the treating health care provider, may render medically necessary treatment until a decision

is rendered.

All treating providers are required to submit all requests on the “Attending Provider Treatment

be found on the NJDOBI web site www.nj.gov/dobi/aicrapg.htm or at Prizm’s web site

www.Prizmllc.com.

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 Licensed health maintenance organizations;

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Date of Service which has already occurred, a decision of Retrospective Date of Service will be rendered.

Pended to IME: If based on the Physician Advisor’s opinion a physical or mental examination is needed to

render a decision, an appointment for an IME (of the same discipline and the most appropriate specialty

related to the treating diagnoses) at a location reasonably convenient to the examinee is scheduled within

seven (7) calendar days of the date of the request. It is noted that medically necessary treatment can

continue while the IME is being scheduled Such treatment shall be subject to retrospective review as the

above provision shall not be construed as to require reimbursement of tests and treatment that are not

requested by the same provider (DOS and CPT codes) or an ancillary provider (related CPT codes to

primary procedure i.e., anesthesia for surgery) a decision of previously requested will be entered and the

decision of the previously requested service will be forwarded to the provider submitting the request.

Please note that the denial of Decision Point Review and Pre-Certification requests on the basis of

medical necessity shall be the determination of a physician. In the case of treatment prescribed by a

dentist, the denial shall be by a dentist.

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examination and of the consequences for unexcused failure to appear at two or more appointments.

The following will constitute an unexcused failure:

If the injured party has two or more unexcused failures to attend the scheduled exam, notification will be

immediately sent to the injured person or his or her designee, and all the providers treating the injured

person for the diagnosis (and related diagnoses) contained in the attending physicians treatment plan

form. This notification will place the injured person on notice that all future treatment diagnostic testing or

durable medical equipment required for the diagnosis and (related diagnosis) contained in the attending

physicians treatment plan form will not be reimbursable as a consequence for failure to comply with the

plan.

Review/ Pre-Certification is authorized a representative of Prizm will contact the vendor and forward the

information to them for scheduling purposes. A representative from the diagnostic facility will contact you,

the injured party, and schedule the test at a time and place convenient to them.

Durable Medical Equipment with a cost or monthly rental over $100.00 is subject to Decision Point

Review/Pre-Certification process and once the Durable Medical Equipment is authorized a representative

of Prizm will contact the vendor and forward the information to them for scheduling purposes. The

equipment will be shipped to you; the injured party from the vendor, 24 hours after the request is received.

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co-payment will not apply.

submit clinically supported findings that support the treatment, diagnostic testing, or durable medical

goods requested will result in a co-payment penalty of (fifty)50%. This co-payment is in addition to any co-

payment stated in the insured’s policy.

Assignment of Benefits

filing litigation including arbitrations will void any and all prior assignment of benefits under this policy.

Please note that any provider that has accepted an assignment of benefits, must comply with and

complete the Appeals Process as noted below prior to initiating arbitration or litigation.

Completing the appeals process means timely submission of an appeal and receipt of the

response prior to filing for Alternative Dispute Resolution. Except for emergency care as defined

in N.J.A.C. 11:3-4.2, any treatment that is the subject of the appeal that is performed prior to the

receipt by the provider of the appeal decision shall invalidate the assignment of benefits.

services or other matters related to the treatment or care of the injured person. For appeals regarding a

decision related to a treatment request, notification to Prizm must occur in writing within thirty (30) days of

the receipt of the decision in question. This appeal must be requested prior to the performance or

issuance of the requested service. This appeal must contain a properly completed Pre-Service Appeal

Form, the original Attending Provider Treatment Plan (APTP) being appealed, the APTP

Decision/Response document being appealed, an appeal rationale narrative, the treating provider’s

signature and the reason(s) for the appeal along with any supporting documentation. Prizm’s response to

the appeal will be communicated to the requesting provider in writing by fax within 14 days of receipt. The

Pre-Service Appeals Form can be accessed on Prizm’s web site at www.Prizmllc.com.

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Marlton, NJ 08053.

If the required information is not submitted at the time the pre-service appeal is received, the appeal will

be denied administratively and will not be addressed. You will be notified of the insufficiencies contained

in their appeal submission and will be given the opportunity to resubmit correctly.

Please note that any provider that has accepted an assignment of benefits or any insured, must comply

with the Appeals Process as noted below prior to initiating arbitration or litigations.

denials or modifications done by a Physician Advisor Review or an IME subsequent to the performance or

issuance of the services, a treating provider must request reconsideration through Prizm. These issues

may include, but are not limited to, bill review or payment for services. This request must be made in

writing within 90 days of receipt of the explanation of benefits and at least 45 days prior to initiating

alternate dispute resolution pursuant to N.J.A.C 11:3-5. The request must include a properly completed

Post-Service Appeal Form in accordance with NJAC 11:3-4.7(d) (as defined in section ii below), the

original Bill (HCFA/UB), the Explanation of Benefit/Payment, the signature of the treating provider and

A properly completed Post-Service Appeal Form must include:

EOB’s require a post-service appeal, a separate Post-Service Appeal Form

should be submitted for each unique EOB ID.

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Prizm’s written response to this appeal will be communicated to the requesting provider by fax or mail

within thirty (30) days after the receipt of the appeal form and any supporting documentation.

Please note that any provider that has accepted an assignment of benefits or any insured, must comply

with the Appeals Process as noted above prior to initiating arbitration or litigations.

Should the assignee choose to retain an attorney to handle the Appeals Process, they do so at their own

expense.

appeal of the denial of a medical procedure, treatment, diagnostic test, other service, and/or durable

medical equipment on the grounds of medical necessity is a different issue than a post-service appeal of

what the insurer should reimburse the provider for that same service. If a provider submits a pre-service

appeal or the modification or denial of treatment by a Physician Advisor Review or an IME and

subsequently performs the services and receives an EOB denial on the basis of the same PAR or IME,

the one-level appeal requirement has been met and the provider is no longer able to appeal the same

issue as a post-service appeal.

Payments/ Reimbursement

most current version of FAIR Health Data Base, consistent with the date of service, 80th percentile and

with the providers’ zip code, as proof of a usual, customary and reasonable fee.

For Pharmacy bills which aren’t noted in a fee schedule, American Commerce Insurance Company will

use the most current version of the Goldstandard with the geozip noted on the provider's address noted on

the provider bill.

If the provider participates in an applicable PPO network, services may be reimbursed in accordance with

the amount permitted under the PPO agreement.

Commerce Insurance Company insurer’s obligation to only reimburse for medically necessary treatment.

To obtain the entire current NCCI edits from the following web site:

www.cms.gov/NationalCorrectCodInitEd/.