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.
Who May Apply for Arbitration Using this Site
Although either a payer or a health care provider may request arbitration of disputed claims, currently this site is designed to accept applications from health care providers only. If you are a payer that would like to initiate an arbitration request, please contact MAXIMUS for instructions on how to proceed. Email email@example.com or call (585) 348-3116. Payers should not attempt to register on this site.
C. 32 Out-of-Network Arbitration (OON) vs. Program for Independent Claims Payment Arbitration (PICPA)
C. 32 OON Arbitration 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 30-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 30 days after the bill is sent.
PICPA Arbitration 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.