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NJ PIP Pre-Service Appeal Form (Version 1.2)

When a New Jersey PIP insurer denies or modifies a decision point review or precertification request, the treating provider uses this uniform form for the internal appeal before the treatment is given. Mandated by Order A17-103 since April 17, 2017, it covers medical necessity disputes, administrative disputes and requests left unanswered for 3 business days. A denied appeal can then go to PIP arbitration.

Who completes it

The treating provider holding an assignment of benefits completes and signs the whole form, including availability for a telephone discussion in items 27 and 28 and the appeal issues in items 30 to 34. A typed electronic signature is acceptable.

Submitting and payment

How to submit it
Send it to the insurer's internal appeals unit or PIP vendor as directed in the insurer's Decision Point Review Plan, with the original APTP, the decision letter and an appeal rationale narrative.
Who pays
The appeal decides whether the patient's PIP insurer will cover the proposed treatment, testing or equipment that the provider bills under the assignment of benefits.

Good to know

  • Use one form per APTP; a single form cannot cover several treatment plans. Extra issues go on a second form completing only items 30 to 34.
  • The 45-day wait before arbitration applies to post-service appeals only; DOBI's FAQ shows a provider seeking arbitration once a pre-service appeal is denied.
  • Item 32 lets the provider appeal when no response to the APTP arrived within 3 business days; items 33 and 34 mark administrative or medical necessity disputes.
  • List only the CPT, HCPCS or NDC codes being appealed, and resend records only if they are new or additional to those sent with the APTP.

Get the official form

Download the current version from the source each time; forms change without notice.

New Jersey PIP Pre-Service Appeal Form

Official pagePDF

Fill it with Vero

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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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When do I use the pre-service rather than the post-service appeal form?

Use the pre-service form to challenge a decision on an APTP request, meaning decision point review or precertification, before the services are rendered. Use the post-service form once services have been performed and billed and the dispute is about payment on an EOB. Each form handles one APTP or one EOB.

What must be attached to a New Jersey pre-service appeal?

The minimum is the original APTP, the insurer's APTP decision or response, and an appeal rationale narrative explaining the basis for the appeal. Independent medical exam, diagnostic and peer review reports can be added. Only new or additional supporting records need to be resent.

Is an internal pre-service appeal required before PIP arbitration?

Yes. Disputes covered by the insurer's Decision Point Review Plan go through the internal appeal first, and unresolved disputes then go to PIP dispute resolution under N.J.A.C. 11:3-5. Unlike post-service appeals, there is no 45-day wait once the insurer denies the pre-service appeal.