Callagy Law attorneys are experts in maximizing
health care providers’ recovery
of Personal
Injury Protection (“PIP”) benefits where the patient elected health
insurance primary and the health carrier denied payment or issued only partial
payment.
By way of background,
when an insured elects health insurance as primary for PIP
medical expense benefits, the medical expense benefits available to the insured
under his or her automobile
policy’s personal injury protection provision become secondary. New Jersey law provides that an automobile
insurer’s obligation to provide PIP benefits is limited to “allowable expenses”
remaining uncovered after all health benefits plans for which the insured is
eligible have paid benefits towards those allowable expenses. In sum, when a health carrier asserts that it
is not required to issue PIP medical
expenses per the policy or law and, thus, will not act as the primary coverage
provider, the automobile insurer shall thereafter assume the role of primary PIP
coverage provider.
In order to pursue a
claim for PIP benefits
on behalf of health care providers seeking reimbursement for their services
where their patient elected health insurance primary, it is imperative that the
health care provider follow the steps listed below:
·
First, submit bill(s) to the patient’s
health carrier;
·
Second, if the health carrier denied
payment or issued only partial payments, the health carrier’s Explanation
of Benefit (“EOB”) form(s) need to be submitted to the patient’s automobile
insurer;
An automobile insurer’s
obligation to pay PIP benefits as
secondary PIP
insurer is triggered by the health carrier’s denial of the health provider’s
bills and the denial is not required to be substantive in nature. Examples of health care denials that have triggered
an automobile carrier’s obligation to pay PIP
benefits as secondary payor are set forth below:
·
Where the health carrier denied payment
due to the fact that the patient failed to submit bills in a timely manner;
·
Where the health carrier denied payment
on the grounds that the patient failed to obtain pre-authorization;
·
Where the health carrier’s EOB indicated
that payment was “pending” based upon a request
for additional information from the patient which was never provided;
·
Where the health carrier’s EOB indicated
that there is “positive no fault information on file, resubmit the claim with
completed no fault letter information” and the requested information was never
provided.
In sum, proper
documentation will maximize health care providers’ success in recovering PIP
reimbursement where the patient elected health insurance primary and the health
insurer denied payment.
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