New Jersey Auto Reform

Dear Provider,

Uniform Attending Provider Treatment Plan Form

All providers treating PIP patients must use the Uniform Attending Provider Plan Form to submit Decision Point and Precertification Requests to Insurers.

Order A16-101: In the Matter of Changes to the Uniform Attending Provider Plan Form and Decision Point Review and Precertification in Personal Injury Protection

http://www.state.nj.us/dobi/pipinfo/aicrapg.htm#uniform

Please print and complete the treatment plan form (from the link below), which must be submitted for precertification requests. Please fax the completed form, along with a copy of the patient’s most recent/appropriate progress notes, supporting medical documentation, and the results of all diagnostic testing relative to the requested services, to the Hoover Precertification Department, at 570.283.1637.

Click the Link to Download: NJ Auto Attending Provider Treatment Plan Form.

Uniform Internal Appeal Forms

Effective April 17, 2017, all providers treating PIP patients must use the Uniform Pre-Service and Post-Service Appeal Forms to submit Internal Appeals to Insurers.

Order A17-103: In the Matter of the Establishment of Uniform Pre-Service and Post-Service Internal Appeal Forms

Please complete and print your Pre-Service or Post-Service Appeal Forms (from the links below), which must be submitted for Appeal requests. Feel Free to Utilize either the PDF or Excel Format.

Please fax the completed form, along with any new information to support the appeal to the Hoover Precertification Department, at 570.283.1637.

Click the Link to Download:

Pre-Service Appeal Form – PDF
Pre-Service Appeal Form Excel
Click the Link to Download:

Post-Service Appeal Form – PDF
Post-Service Appeal Form Excel

If you have any questions, please call us at 1.877.704.4440, or email us.

Decision Point Review Program

Click on the Link to Download:

Decision Point Review Precertification Program Description and Summary