If you are involved in an automobile accident, you must report the accident to your local Amica branch office as soon as possible. We may impose a co-payment penalty if the accident is not reported to us within 30 days.
New Jersey insurance regulations establish standard courses of treatment (care paths) for certain neck, back, and soft tissue injuries that may result from an auto accident. These injuries are known as "identified injuries". Treatment proposed for identified injuries must conform to the care paths, copies of which may be obtained by contacting either Amica or Prizm Solutions. Care paths require that treatment be evaluated at intervals called decision points. At decision points, you or your health care provider must provide our utilization vendor with information about intended further treatment. The vendor will review and make a determination regarding your continued treatment. This is called a decision point review. The administration of any test listed on EXHIBIT B also requires decision point review, regardless of diagnosis. Prior review of medical treatment or tests is not needed for emergency care following an accident or for treatment received within 10 days of an accident.
We have contracted with a medical review organization to monitor medical treatment for injuries sustained in automobile accidents. The following material summarizes the steps that must be taken if you are to receive maximum reimbursement for the cost of treating your injuries. No coverage is provided by this summary. This summary cannot be construed to replace any provision of your policy. You should read your policy and review your Declarations page for complete information on the coverages that are provided. If there is any conflict between the policy and this summary, THE PROVISIONS OF THE POLICY SHALL PREVAIL.
If you are involved in an automobile accident:
When you report an accident, we will:
We will then notify our decision point review/ precertification organization that you have been injured. Our decision point review/ precertification plan organization is:
Premier Prizm Solutions
10 Stowe Road
Suite 100
Marlton, NJ 08053
Phone: 1-856-596-5600
Fax No. 1-856-596-6300
www.PrizmSolutions.biz
Please note: Prior review of medical treatment or tests is not needed for emergency care following an accident, or for treatment received within 10 days of the accident.
When notified of the accident, Prizm will:
For your convenience, we have made available to you a copy of the New Jersey Department of Banking & Insurance's Attending Provider Treatment Plan Form.
Penalty for Late Notification
If the accident is not reported to us within 30 days, we may reduce any payment you receive for covered injuries as follows:
Any reduction will affect reimbursement for covered medical expenses you incur beginning 30 days after the accident and until we are notified of the accident. The reduction will be applied:
Diagnostic tests and other medical services
New Jersey insurance regulations establish standard courses of treatment (Care Paths) for certain neck, back and soft tissue injuries that may result from an auto accident. These injuries are known as "identified injuries". Exhibit A contains a list of the identified injuries. Treatment proposed for identified injuries must conform to the Care Paths, unless special circumstances indicate that other treatment is medically necessary. A copy of the Care Paths can be obtained from Amica or Prizm. For any type of injury, New Jersey Insurance regulations require that the use of certain diagnostic tests be reviewed and monitored. These diagnostic tests are listed in Exhibit B. In addition, if you do not have an identified injury, we require that a number of medical services be reviewed and monitored. These services are also listed in Exhibit B.
New Jersey insurance regulations and your policy provide that no coverage will be afforded under your personal injury protection coverage for the following diagnostic tests:
Decision Point Review / Precertification Procedure
Your doctor will be asked to submit a comprehensive treatment plan for your injuries. Prizm will review the plan. The plan will be approved if Prizm agrees that the treatment proposed is medically necessary. Your doctor will be notified of the outcome of the review within three (3) business days of Prizm's receipt of all necessary information. Treatment may continue while Prizm reviews the treatment plan. However, you and your doctor should be aware that your policy affords coverage only if treatment is determined to be medically necessary.
If your doctor submits a treatment plan and the plan is approved:
If no treatment plan is submitted, and you have an identified injury (see Exhibit A):
If no treatment plan is submitted, and you do not have an identified injury:
Consequences of Failure to Notify Prizm as Required
Unless the use of medical products and services is approved as part of a comprehensive treatment plan, Prizm must receive at least three (3) business days notice:
You will be notified of Prizm's decision within three (3) business days.
You will be responsible for a co-payment of 50% of the expenses for medical services or products if Prizm as required. This means you must first pay your deductible plus any applicable co-payment, and will then be responsible for 50% of any remaining medical expenses for these medical services.
No coverage will be afforded for treatment or services that are not medically necessary.
Appeal Procedure
If Prizm's Physician Advisor has determined that treatment is not medically necessary, coverage for the treatment will be denied. The written decision will be faxed followed by mail. Prizm's Physician Advisor will be available to discuss the decision with your doctor. Prizm will grant a request for reconsideration of its decision when additional information can be provided to Prizm for a second review. If reconsideration cannot resolve the difference of opinion, the matter may be appealed.
You and/or your doctor may file a standard appeal with us within ten (10) days of Prizm's decision denying coverage. This appeal may be made in writing by fax, mail or accessing the Internal Dispute Form on Prizm's website. If the treating provider has accepted assignment of benefits then the treating provider must agree or submit disputes to our internal dispute resolution process prior to submitting any disputes through the National Arbitration Forum as per N.J.A.C. 11:3-5. If an emergency arises, your doctor can request an expedited appeal for medical services that should not be delayed.
For appeals, you and your doctor will be notified by fax of our determination within ten (10) business days of Prizm's receipt of any information needed to conduct the appeal review.
Should the appeal process fail to resolve the dispute regarding the medical necessity of treatment, the matter may be submitted by either party to a Dispute Resolution Organization named by the state of New Jersey.
What else?
If they are determined to be medically necessary, the following medical products and services will be available through Prizm's network of member providers:
If you purchase these items through Prizm's network of providers, expenses incurred will be fully covered subject to policy provisions if:
With the exception of prescription drugs, you will be responsible for a co-payment of 30% if the above circumstances are met but you do not purchase the available items through Prizm's network. This means you must first pay your deductible plus any applicable co-payment amounts, and will then be responsible for 30% of the remaining costs for the products and services.
A $10.00 co-payment will apply to the purchase of prescription drugs if they are not obtained through Prizm's network. The $10.00 co-payment will apply each time a prescription is filled or re-filled.
You will be responsible for a co-payment of 50% of the expenses for the items available through Prizm's network if you do not receive authorization from Prizm as required. This means you must first pay your deductible plus any applicable co-payment amounts, and will then be responsible for 50% of the remaining costs for the products and services. Notification is not required prior to the purchase of prescription drugs.
Physical Exams Required By Your PolicyIf we are unable to determine if further treatment, diagnostic testing, or use of durable medical equipment is necessary, you may be required to submit to a physical examination. This examination will be scheduled within seven (7) calendar days of the receipt of notice by a doctor in the same discipline as the treating provider and at a location reasonably convenient to you. You are required to provide medical records and other pertinent information to the provider conducting the exam. The records shall be provided at the time of the examination or before. We will notify you no later than (3) three business days after the examination regarding whether or not we will reimburse you for any further treatment, diagnostic tests, or use of durable medical equipment. Expenses will not be reimbursable if there is repeated unexcused failure to attend the required exams.
If you have any questions about the above information, please call us.
Amica Insurance Company
| Northern New Jersey Office One Maynard Drive Suite 301 Park Ridge, NJ 07656-1878 Toll Free 800-762-6422 |
Southern New Jersey Office 10000 Midlantic Drive Suite 403 West Mount Laurel, NJ 08054-1559 Toll Free: 1-888-592-6422 |
EXHIBIT A
Identified Injuries
The following neck, back and soft tissue injuries are known as "identified injuries" under New Jersey insurance regulations. The regulations contain standard courses of medical treatment known as Care Paths for these injuries. Treatment for identified injuries must conform to the Care Paths unless other treatment is determined to be medically necessary.
| ICD-9 Code | Description |
| 722.0 | Displacement of cervical intervertebral disc without myelopathy |
| 722.1 | Displacement of thoracic or lumbar intervertebral disc without myelopathy |
| 722.10 | Displacement of lumbar intervertebral disc without myelopathy |
| 722.11 | Displacement of thoracic intervertebral disc without myelopathy |
| 722.2 | Displacement of intervertebral disc, site unspecified, without myelopathy |
| 722.70 | Intervertebral disc disorder with myelopathy, unspecified region |
| 722.71 | Intervertebral disc disorder with myelopathy, cervical region |
| 722.72 | Intervertebral disc disorder with myelopathy, thoracic region |
| 722.73 | Intervertebral disc disorder with myelopathy, lumbar region |
| 728.0 | Disorders of muscle, ligaments and fascia |
| 728.85 | Spasm of muscle |
| 739.0 | Non-allopathic lesions - not elsewhere classified |
| 739.1.1.1 | Somatic dysfunction of cervical region |
| 739.1.1.2 | Somatic dysfunction of thoracic region |
| 739.3 | Somatic dysfunction of lumbar region |
| 739.4 | Somatic dysfunction of sacral region |
| 739.8 | Somatic dysfunction of rib cage |
| 846.0 | Sprains and strains of sacroiliac region |
| 846.1 | Sprains and strains of lumbosacral (joint)(ligament) |
| 846.2 | Sprains and strains of sacrospinatus (ligament) |
| 846.3 | Sprains and strains of sacrotuberous region |
| 846.8 | Sprains and strains of other specified sites of sacroliliac region |
| 846.9 | Sprains and strains of unspecified site of sacroiliac region |
| 847.0 | Sprains and strains of neck |
| 847.1 | Sprains and strains, thoracic |
| 847.2 | Sprains and strains, lumbar |
| 847.3 | Sprains and strains, sacrum |
| 847.4 | Sprains and strains, coccyx |
| 847.9 | Sprains and strains of back, unspecified site |
| 922.3 | Contusion of back |
| 922.31 | Contusion of back, excludes interscapular region |
| 922.33 | Contusion of back, interscapular region |
| 953.0 | Injury to cervical root |
| 953.2 | Injury to lumbar root |
| 953.3 | Injury to sacral root |
EXHIBIT B
DIAGNOSTIC TESTS
Beginning on the eleventh day following an automobile accident, Prizm must receive at least three (3) business days notice if the following diagnostic tests are planned:
OTHER MEDICAL SERVICES AND PRODUCTS
Beginning on the eleventh day following an automobile accident, Prizm must receive at least three (3) business days notice if use of the following medical services and products is planned:
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