New Jersey DPR/Pre-Certification
The New Jersey Automobile Insurance Cost Reduction Act of 1998 – AICRA provides the regulatory structure for administering a Decision Point Review (DPR) program, but the manner in which the program is managed by both the carrier and the plan administrator greatly affects patient and claims outcomes. Auto Injury Solutions provides the insurance carrier with options for Traditional DPR/Pre-Certification and Proactive Case Management program management to achieve successful outcomes.
Our Medflow Technology Suite provides visibility into the progress of a case under management for the adjuster through the web-based Medflow Adjuster Desktop, as well as provides an entirely electronic internal workflow for addressing DPR/Pre-Certification requests, physician review, IME referral, medical bill review, and access to all medical documentation associated with the claim. Additionally, each DPR/Pre-certification event is tracked within the Medflow Technology Suite to provide an audit trail that supports compliance with regulatory timeframes.
Traditional DPR/Pre-Certification
AIS offers a traditional DPR/Pre-Certification program for submission and review of DPR/Pre-Certification requests by a Nurse Case Manager as well as physician advisor reviews (PHAD) which allows licensed physicians to utilize state medical protocols to serve as a measure of comparison to identify unnecessary or inappropriate treatment and subsequently notifying the eligible injured person, attending physician, and attorney of any DPR/Pre-Certification determinations.
Traditional DPR/Pre-Certification is offered in conjunction with AIS Medical Bill Review services or can be provided as a stand-alone service feeding case management information to the insurer’s applications.
Proactive Case Management
The AIS Proactive Case Management approach employs direct contact with all parties at the point of referral and at regular intervals throughout the life of the claim with the goal of managing the case, not just the DPR / Pre-Certification event.
- Immediate assignment of the case to a Nurse Case Manager
- Outbound contact to the eligible injured party, their representatives, and their care providers to determine causality and medical necessity
- Determination of Care Path/Medical Protocols - Nurse Case Managers determine course of treatment and conduct discharge planning assessment with the treating provider
- Determination of need for Independent Medical Examination
- Assessment of need for SIU referral
- 30 Day Follow-up contacts throughout the life of the case
- Review of Attending Physician Treatment Plans with appropriate recommendation to Physician Advisor Review and Determination (PHAD)
- Outbound notifications as required by DRP Plan