Program for Independent Claims Payment Arbitration (PICPA) Application
Eligibility for the PICPA
The PICPA is designed to consider only a segment of claims disputes. A claim is eligible for arbitration only if:
The claim was payable by an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, prepaid prescription service organization, or its agent, including an organized delivery system (ODS) or a third party administrator (TPA), pursuant to the terms of a health benefits plan issued in this State. Disputes of claims payable by the following are not eligible for consideration by the PICPA:
- A self-funded entity;
- The State Health Benefits Program;
- Medicaid (other than Medicaid managed care claims);
- The Federal Employees Health Benefits Program;
- A dental service corporation;
- A dental plan organization (DPO);
- Any carrier paying claims in accordance with personal injury protection, or bodily injury protection provisions of an automobile policy, worker's compensation policies, or similar such provisions of other liability policies;
- The claim arises from health care services rendered on or after July 11, 2006;
- The health care provider appealed the denied or disputed claim to the payer within 90 days of the claim payment determination by submitting the Health Care Provider Application to Appeal a Claims Determination form to access the internal claims appeal process; The payer's internal HCAPPA claim appeal process was completed, OR the payer failed to comply with the processing and review timeframes with respect to the claim, and the health care provider has documentation supporting that contention;
- The amount in dispute is $1,000 or more;
- When aggregating claims (for the purpose of reaching the $1,000 threshold), a health care provider aggregates claims by carrier and covered person OR by carrier and CPT code; and
- The health care provider submits the application for arbitration timely with the appropriate fees.
The NJ Department of Banking and Insurance has set forth the following deadlines for timely submission of applications for arbitration, and rendering of arbitration decisions:
- If the claims appeals was completed, or should have been completed, on or before July 31, 2007, then the application for arbitration must be completed and fees submitted by November 30, 2007, and MAXIMUS will render a decision within 60 calendar days following receipt of application, documentation and fees.
- If the claims appeals was completed, or should have been completed, on or after August 1, 2007, then the application for arbitration must be completed and fees submitted within 90 days following the date the claims appeal was completed, or should have been completed by the payer, and MAXIMUS will render a decision within 30 calendar days following receipt of application, documentation and fees.
Through this site, health care providers may submit an Application for Arbitration online, and attach supporting documentation if the information is in an electronic format, including scanned documents. To complete an application, a health care provider must first Register by clicking here. (After initial registration, health care providers will receive an email or phone call with login details within 48 business hours. You may not login to create cases until you receive your login details from MAXIMUS.)
The following documentation should be submitted with your application:
- All information related to your internal claims appeal, including a copy of the Health Care Provider Application to Appeal a Claims Determination, and the payer's decision, if any.
- All relevant medical records and billing records (HCFA 1500, UB92s).
- All relevant correspondence between the health care provider and payer.
- All relevant coding or reimbursement policies, including contracted fee documentation, guidelines, data (e.g., Ingenix), or literature.
- Although not required, a completed Consent to Representation in Appeals of Utilization Management Determinations and Authorization for Release of Medical Records in UM Appeals and Independent Arbitration of Claims (Consent) should be submitted if the party requesting arbitration wants medical records reviewed by the arbitrator.*
* While a (Consent) is not required for the PICPA process, a missing or incomplete member consent may impact the information available to the arbitrator from the medical record which, in turn, may affect the arbitrator's decision. The Consent form is available on-line at the Departments website at www.state.nj.us/dobi/chap352/352consentform.doc
Fees and Payment
The application and arbitration process is composed of two parts, and there is a separate fee for each part of the process. The Initial Review determines whether your request qualifies for actual arbitration based on the information submitted. If the request qualifies, then the matter will go to arbitration for a decision on the case. However, to complete your application, you must send fees for both the Initial Review and the Arbitration.
Send two checks (or money orders) made payable to MAXIMUS at the address above. The separate checks should be made for amounts consistent with the following:
- Initial Review Fee -- $72.50 for every claim submitted with a disputed amount of $1,000 or more OR $72.50 for every $1,000 in dispute for aggregated claims of less than $1,000 each.
- Arbitration Fee -- $150.00 for every claim submitted with a disputed amount of $1,000 or more OR $150.00 for every $1,000 in dispute for aggregated claims of less than $1,000 each.
Alert:Your case may be disaggregated. MAXIMUS is permitted under the PICPA process to disaggregate cases when appropriate. Cases involving multiple lines of code and more than $2,000 may be disaggregated. You will be notified if your case is disaggregated. Please be aware that additional initial review fees and arbitration fees will be required if your case is disaggregated.
Initial Review and Arbitration Review
After receiving the health care provider's completed application, MAXIMUS will contact the payer for a response, documentation, and payment of its portion of the fees. MAXIMUS will review the application and all documentation, and will contact the parties as to whether the request has been accepted for arbitration.
In some cases, MAXIMUS may need to request additional information from the party initiating arbitration, the responding party, or both. MAXIMUS will make such requests to the appropriate party in writing, and the party will have ten days to respond with the requested information in writing. Health care providers and Payers will have to send the requested information by regular mail, courier service, secure email or secure facsimile, to:
Reviews will be based solely on the submitted documentation. Reviews will be performed by independent and impartial health claims professionals with at least five years of claims processing experience. MAXIMUS will forward the written results of the Arbitration to the initiating party, responding party, and the New Jersey Department of Banking and Insurance within 30 calendar days following receipt of the documentation necessary for making a decision.
If you have any problems completing your application or you have questions regarding the arbitration process and other administrative matters, please contact MAXIMUS via email at firstname.lastname@example.org, or by phone at (585) 348-3116. Please note that MAXIMUS will not accept verbal arguments for inclusion in the case record.