New Jersey § 39:6a-5

§ 39:6a-5.

a. Any dispute regarding the recovery of medical expense benefits or other benefits

provided under personal injury protection coverage pursuant to section 4 of P.L.1972,

c. 70 ( C.39:6A-4 ), section 4 of P.L.1998, c. 21 ( C.39:6A-3.1 ) or section 45 of P.L.2003, c.89 ( C.39:6A-3.3 ) arising out of the operation, ownership, maintenance or use of an automobile may

be submitted to dispute resolution on the initiative of any party to the dispute,

as hereinafter provided. b. The Commissioner of Banking and Insurance shall designate an organization, and

for that purpose may, at his discretion, advertise for proposals, for the purpose

of administering dispute resolution proceedings regarding medical expense benefits

and other benefits provided under personal injury protection pursuant to section 4

of P.L.1972, c. 70 ( C.39:6A-4 ) , medical expense benefits coverage pursuant to section 4 of P.L.1998, c. 21 ( C.39:6A-3.1 ) or emergency care medical expense benefits pursuant to section 45 of P.L.2003, c. 89 ( C.39:6A-3.3 ) . The commissioner shall promulgate rules and regulations with respect to the conduct

of the dispute resolution proceedings. The organization administering dispute resolution shall utilize qualified professionals

who serve on a full-time basis and who meet standards of competency established by

the commissioner. The commissioner shall establish standards of performance for the organization to

ensure the independence and fairness of the review process, including, but not limited

to, standards relative to the professional qualifications of the professionals presiding

over the dispute resolution process, and standards to ensure that no conflict of interest

exists which would prevent the professional from performing his duties in an impartial

manner. The standards of performance shall include a requirement that the organization establish

an advisory council composed of parties who are users of the dispute resolution mechanism

established herein. The commissioner may contract with a consulting firm for the formulation of the

standards of performance of the organization and establishment of qualifications for

the persons who are to conduct the dispute resolution proceedings. The commissioner shall not advertise for bids for the consulting firm, as provided

in sections 3 and 4 of P.L.1954, c. 48 (C.52: 34-8 and 52:34-9). Compensation to the dispute resolution professionals shall be established by the

commissioner and adjusted from time to time as appropriate, with the approval of the

commissioner. In no case shall compensation be paid on a contingency basis. The organization shall establish a dispute resolution plan, which shall include

procedures and rules governing the dispute resolution process and provisions for monitoring

the dispute resolution process to ensure adherence to the standards of performance

established by the commissioner. The plan, and any amendments thereto, shall be subject to the approval of the commissioner. c. Dispute resolution proceedings under this section 24 and section 25 of this amendatory

and supplementary act shall include disputes arising regarding medical expense benefits

provided under subsection a. of section 4 of P.L.1972, c. 70 ( C.39:6A-4 ) , section 4 of P.L.1998, c. 21 ( C.39:6A-3.1 ) or section 45 of P.L.2003, c. 89 ( C.39:6A-3.3 ) , benefits provided pursuant to subsection b., c., d. or e. of section 4 of P.L.1972,

c. 70 ( C.39:6A-4 ), subsection b., c., d. or e. of section 7 of P.L.1972, c. 198 ( C.39:6-86.1 ), and disputes as to additional first party coverage benefits required to be offered

pursuant to section 10 of P.L.1972, c. 70 ( C.39:6A-10 ). Disputes involving medical expense benefits may include, but not necessarily be

limited to, matters concerning: (1) interpretation of the insurance contract; (2)

whether the treatment or health care service which is the subject of the dispute resolution

proceeding is in accordance with the provisions of section 4 of P.L.1972, c. 70 ( C.39:6A-4 ) , section 4 of P.L.1998, c. 21 ( C.39:6A-3.1 ) or section 45 of P.L.2003, c. 89 (C.39: 6A-3.3) or the terms of the policy; (3) the eligibility of the treatment or service for

compensation; (4) the eligibility of the provider performing the treatment or service

to be compensated under the terms of the policy or under regulations promulgated by

the commissioner, including whether the person is licensed or certified to perform

such treatment; (5) whether the disputed medical treatment was actually performed;

(6) whether diagnostic tests performed in connection with the treatment are those

recognized by the commissioner; (7) the necessity or appropriateness of consultations

by other health care providers; (8) disputes involving application of and adherence

to fee schedules promulgated by the commissioner; and (9) whether the treatment performed

is reasonable, necessary, and compatible with the protocols provided for pursuant

to P.L.1998, c. 21 ( C.39:6A-1.1 et al.). The dispute resolution professionals may review the entire claims file of the insurer,

subject to any confidentiality requirement established pursuant to State or federal

law. All decisions of the dispute resolution professional shall be in writing, in a form

prescribed by the commissioner, shall state the issues in dispute, the findings and

conclusions on which the decision is based, and shall be signed by the dispute resolution

professional. All decisions of a dispute resolution professional shall be binding. The dispute resolution organization shall provide for the retention of all documents

used in dispute resolution proceedings under this section and section 25 of this amendatory

and supplementary act, including the written decision, for a period of at least five

years, in a form approved by the commissioner, or for such additional time as may

be established by the commissioner. The written decisions of the dispute resolution professional shall be forwarded

to the commissioner, who shall establish a record of the proceedings conducted under

the dispute resolution procedure, which shall be accessible to the public and may

be used as guidance in subsequent dispute resolution proceedings. d. With respect to disputes as to the diagnosis, the medical necessity of the treatment

or diagnostic test administered to the injured person, whether the injury is causally

related to the insured event or is the product of a preexisting condition, or disputes

as to the appropriateness of the protocols utilized by the provider, the dispute resolution

professional shall, either at his option or at the request of any party to the dispute,

refer the matter to a medical review organization for a determination. The determination of the medical review organization on the dispute referred shall

be presumed to be correct by the dispute resolution professional, which presumption

may be rebutted by a preponderance of the evidence. Should the dispute resolution professional find that the decision of the medical

review organization is not correct, the reasons supporting that finding shall be set

forth in the dispute resolution professional's written decision. e. Any person submitting a matter to the dispute resolution process established herein

may submit for review all or a portion of a disputed treatment or treatments or a

dispute regarding a diagnostic test or tests or a dispute regarding the providing

of services or durable medical goods. Any portion of a treatment or diagnostic test or service which is not under review

shall be reimbursed in accordance with the provisions of section 5 of P.L.1972, c.

70 ( C.39:6A-5 ). If the dispute resolution proceeding results in a determination that all or part

of a treatment or treatments, diagnostic test or tests or service performed, or durable

medical goods provided are medically necessary and appropriate, reimbursement shall

be made with interest payable in accordance with the provisions of section 5 of P.L.1972,

c. 70 ( C.39:6A-5 ).