New Jersey's 21-day notice rule (N.J.A.C. 11:3-25) requires a treating health care provider to tell the patient's PIP insurer, within 21 days, that treatment has begun for injuries from an auto accident. Appendix A is the one-page notification the rule prescribes. Within 14 days of receiving it, the insurer must tell the provider the patient's coverage status.
The treating health care provider completes the whole form: provider name and contact details, the patient's and insured's names and addresses, the insurer, policy number, date of accident and date of first treatment. That information may come from the insured, the injured person, the hospital or a police report.
Download the current version from the source each time; forms change without notice.
Notification of Commencement of Medical Treatment
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The insurer must tell the provider in writing and may reduce eligible charges: 10% at 22 to 30 days, 25% at 31 to 60, 50% at 61 to 120, 75% at 121 to 160 and 100% at 161 days or more. Insurers may reduce less after weighing factors such as a pattern of late notice, and the provider may not bill the patient for the cut.
Yes. N.J.A.C. 11:3-25.4 lets a bill or invoice that contains at least the Appendix A information serve as notice, but only if its first page carries 21 DAY NOTICE or FIRST BILL 21 DAY NOTICE in contrasting color ink, in 12-point or larger capital letters. A rubber stamp or affixed label is acceptable.
Secondary medical providers, who supply products or services only on another provider's prescription, such as pharmacists, visiting nurses, prosthetics fabricators and DME suppliers, are exempt. The exemption does not cover physical therapists, chiropractors, or secondary providers whose charges exceed the rule's threshold for one occasion or a 30-day period.