WHAT DOES DECISION POINT REVIEW OR PRE-CERTIFICATION MEAN TO YOUR CLAIM FOR PIP BENEFITS?

The following information was prepared for insured's and claimants covered under a Travelers Auto Insurance Company of New Jersey automobile insurance policy. It provides information regarding how a claim for medical benefits pursuant to the Personal Injury Protection Coverage will be handled. If there is any conflict between this summary and the policy, the policy terms are controlling and will prevail.

Please be advised that if you are injured in an automobile accident you must report the claim to us as promptly as possible after the accident. Your notice to us must include the facts surrounding the accident, the nature and cause of any injury, the diagnosis and the anticipated course of treatment. You may contact us by telephone to advise us of the accident, by calling 1-800-468-7341 and/or fax the required information to (866)296-4180.

Failure to provide us with the required information within 30 days of the accident may result in a co-payment penalty that would significantly reduce the amount of reimbursement for eligible charges for medically necessary expenses that would otherwise be payable.

Decision Point Review

Under New Jersey Regulation, the Department of Banking and Insurance has published standard courses of treatment known as Care Paths for soft tissue injuries of the neck and back. These Care Paths furnish your medical provider with standard courses of treatment and diagnostic tests that will be reimbursable under the policy. The Care Paths include requirements that your medical provider consult with us at certain intervals during your treatment. These are called Decision Points. If your medical provider fails to submit requests for Decision Point Reviews, or fails to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested, payment of your medical provider's bills may be subject to a 50% co-payment penalty even if the services are later determined to be medically necessary. This 50% co-payment penalty applies to reimbursement for medically necessary treatment occurring between the time notification to us was required and the time proper notification is made and we have had an opportunity to respond in accordance with our Decision Point Review Plan. Also, Decision Point Review is required prior to the administration of specific diagnostic tests. Failure to submit requests for Decision Point Reviews for diagnostic tests may also be subject to a 50% co-payment penalty .

The following tests are subject to Decision Point Review:

• Needle electromyography (needle EMG);
• Somasensory evoked potential (SSEP), Visual evoked potential (VEP), brain audio evoked potential (BAEP), brain evoked potential (BEP) nerve conduction velocity(NCV) or H-reflex study;
• Thermography/thermograms;
• Electroencephalogram (EEG);
• Videofluoroscopy;
• Computer assisted tomographic studies (CT, CAT Scan);
• Dynatron/cyber station/cybex;
• Sonograms/ultrasound;
• Brain mapping;
• Magnetic resonance imaging (MRI); and
• Any other diagnostic test that is subject to the requirements of Decision Point Review by New Jersey law or regulation.

These diagnostic tests must be administered in accordance with New Jersey Department of Banking and Insurance regulations, which set forth the requirements for the use of diagnostic tests in evaluating injuries sustained in an auto accident.

We will authorize or deny reimbursement for treatment or testing at a Decision Point Review within 3 business days. If we do not respond to the request for authorization within 3 business days treatment may proceed, until you and the provider are otherwise notified.

Pre-certification

New Jersey Regulation also provides that insurers may require pre-certification of certain treatments or diagnostic tests for other types of injuries or tests not included in the Care Paths.

Pre-certification means that your medical provider is required to provide us with notification of intended medical procedures, treatments, diagnostic tests or other services, non-medical expenses and durable medical equipment over $50. A medical professional will review the treatment plan submitted by your medical provider to determine that you are receiving the appropriate level of medical care and that the treatment plan is medically necessary. Your medical provider must submit a treatment plan and/or request approval for specified treatment and diagnostic testing outlined in the policy. We will authorize or deny the medical procedure or test within 3 business days. If we do not respond to the request for authorization within the 3 business days, treatment may proceed until we notify your provider otherwise.

If your medical provider fails to submit the appropriate request for Pre-certification or fails to provide clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested, payment for services will be subject to a 50% co-payment penalty even if the services are determined to be medically necessary. This 50% co-payment penalty applies to reimbursement for medically necessary treatment occurring between the time notification to us was required and the time proper notification is made and we have had an opportunity to respond in accordance with our Decision Point Review Plan.

The following require pre-certification:

1. Non-emergency inpatient or outpatient hospital care;
2. Non-emergency surgery performed at a hospital, surgi-center, office, etc.
3. Physical, occupational, speech, cognitive or other restorative therapy or body part manipulation except for that provided for the Identified Injuries in accordance with Decision Point Review;
4. Outpatient psychological/psychiatric testing and/or services;
5. All pain management services except as provided for Identified Injuries in accordance with Decision Point Review;
6. Treatment for Carpal Tunnel Syndrome;
7. Treatment for Temporomandibular joint (TMJ/TMD) disorders and oral facial syndrome; and
8. Durable medical equipment (including orthotics and prosthetics) with a cost or monthly rental in excess of $50.

Decision Point Review and Pre-certification Compliance Requirements

In order to submit Decision Point Review and Pre-certification requests, your medical provider must submit a completed Attending Provider Treatment form via fax to (866)296-4180 along with clinically supported findings that support the treatment, diagnostic test or durable medical equipment requested.  A copy of the Attending Provider Treatment form is attached hereto and can also can be found on the Internet on the New Jersey Department of Banking and Insurance website. When we are in contact with your medical provider, we will furnish information regarding the types of treatment or services requiring Decision Point Review or Pre-certification.

Our authorization will be based upon the medical necessity of these medical expenses. Any denial of payment for lack of medical necessity shall be based on the determination of a physician and in the case of treatment prescribed by a dentist, the denial shall be based upon the determination of a dentist.

Decision Point Review and Pre-certification DO NOT apply to emergency care or any medically necessary treatment during the 10 days immediately following the accident.

Internal Appeal Procedure

If treatment, diagnostic testing or durable medical equipment is not authorized by us or if a bill has not been reimbursed to the satisfaction of you or your medical provider an appeal of the dispute can be made. The request must be made in writing by you or the provider, by completing the Internal Appeal Request Form, attached hereto and faxing it to 1-866-296-4180. If the appeal concerns an adverse decision regarding the request for authorization of treatment, diagnostic testing or durable medical equipment, the appeal shall be made within 30 days of the original non-certification determination.

The request for appeal will be referred to a physician for review. These Appeals will be responded to within 14 days of receipt of the written request accompanied by clinically supported documentation. In cases where there is imminent or ongoing services requiring review, the Appeal will be responded to within 3 days of receipt of the written request accompanied by clinically supported documentation. Any pertinent additional information supplied with the appeal request is also forwarded to the physician for review.

Dispute Resolution Process

All disputes, including those that have not been resolved in the Internal Appeal Procedure, may be submitted through the Personal Injury Protection Dispute Resolution process that is governed by N.J.A.C. 11:3-5, by initiating the process with National Arbitration Forum (NAF). NAF can be contacted via telephone at 1-800-747-2347 or via heir website, www.arb.forum.com.

Please note however, unless the dispute involves a request for emergent relief, you or the medical provider shall advise the Claims Adjuster assigned to the matter in writing of the nature of the dispute and the specific issues in dispute within 14 days of initiating litigation or the Personal Injury Protection Dispute Resolution process.

Physical Examinations

During the course of your treatment, it may be necessary for you to attend a physical exam so that we can determine the medical necessity of further treatment, diagnostic testing or durable medical equipment. When there is a need for a physical exam, the examination will be conducted by a provider in the same discipline as the treating provider and the examination will be conducted at a location that is reasonably convenient for you.

The appointment for the physical examination will be scheduled within seven days of our notification to you and the insured’s provider, unless you agree to extend this time period. Please note that treatment may proceed while the hysical examination is being scheduled and until the results are made available. However, please be advised that only treatment that is medically necessary is reimbursable pursuant to the policy of insurance.

We may request that you produce medical records at or before the physical examination. You and your provider will be advised of the need to produce the requested records.

We will notify you or your designee and the treating provider whether we will reimburse for further treatment, diagnostic tests or durable medical equipment as promptly as possible, but no later than three business days after the examination is completed and the requested records have been supplied.

Upon your request, we will provide copies of the written report of the examination physician, if a report was prepared as a result of the examination.

In the event that you have failed to appear at a scheduled physical examination, we will advise you that if there is a epeated unexcused failure to attend a scheduled examination, we will deny reimbursement for any treatment for the diagnosis that necessitated the scheduling of the physical exam due to your failure to comply with our requests under the policy.

When you have had repeated unexcused failures to appear at scheduled physical examinations, you will be sent the notice terminating the benefits otherwise available under the policy.

Voluntary Networks

If you or your provider voluntarily utilizes a conveniently located designee selected by our company to obtain a Magnetic Resonance Imaging (MRI), we will waive the 30% co-payment that would otherwise apply. You or your rovider may contact Raytel Imaging Network, our designee selected to perform the MRI, to locate a conveniently located facility, by calling their toll-free number 1(800) 453-0574 or by reviewing the list of facilities on their website. Once approval is obtained for the performance of the MRI you or your provider may schedule the appointment by contacting Raytel at 1(800)453-0574.

Co-payment Penalties

The additional 50 % co-payment penalty noted above may significantly reduce payments to medical providers who fail to comply with Decision Point Reviews and pre-certification requirements. This co-payment is in addition to any deductible required under the Personal Injury Protection coverage. Furthermore, the following co-payment penalties ill apply as a result of your failure to provide the Company with the necessary information as promptly as possible following the accident:

• 25% co-payment penalty for notice that is provided 30-59 days after the loss;
• 50% co-payment penalty for notice that is provided 60 or more days after the loss.

This co-payment is in addition to any co-payment or deductible required under the policy and in accordance with statute or regulation.

Assignment of Benefits

These benefits shall not be assignable except to providers of service benefits. We will make direct payments to a medical provider only if you and the provider completes our Conditional Assignment of Benefits. As a condition of the Assignment of Benefits the medical provider must agree to (including but not limited to):

1. Comply with all of the requirements of this Decision Point Review Plan;
2. Comply with all our requests for additional information concerning the presentation of the claim   including but not limited to the submission of medical records with clinically supported findings to support the diagnosis, casual relationship to the accident and care plan and if necessary submit to Examinations Under Oath;
3. Submit all disputes in accordance with the Internal Appeal Procedure set forth in this Decision Point Review Plan. Only after final determination of the Internal Appeal Procedure, will the medical provider institute litigation or initiate Personal Injury Protection Dispute Resolution process; and
4. Hold harmless the insured or claimant for any co-payment penalty or reduction of payment for services caused by the provider’s failure to comply with the terms of this Decision Point Review Plan, insofar as the medical provider will not seek reimbursement for such penalty from the insured or claimant for any unpaid portion of the bill attributable to such failure to comply with this Decision Point Review Plan.

If you would like additional information regarding Decision Point Review or Pre-certification, information is available on the Internet on the New Jersey Department of Banking and Insurance website. If you are a claimant, you can receive additional information by calling your claims representative.

ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.