PIP Insurance Billing Guide - Davis Law Group, P.S.

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Transcript of PIP Insurance Billing Guide - Davis Law Group, P.S.

Da

vis

La

w G

rou

p,

P.S

.

21

01

Fo

urt

h A

ve.,

Su

ite

63

0

Sea

ttle

, W

A 9

81

21

20

6.7

27

.40

00

Da

visL

aw

Gro

up

Sea

ttle

.co

m

Mo

torc

ycl

e A

ccid

en

ts

Pri

ma

ry

PIP

no

t a

uto

ma

tica

lly r

eq

uir

ed

fo

r

mo

torc

ycle

po

licie

s. I

f P

IP e

xist

s,

bill

th

e P

IP o

r M

ed

Pa

y fo

r th

e

pa

tie

nt’

s m

oto

rcyc

le p

olic

y.

Se

con

da

ry

If p

ati

en

t w

as

pa

sse

ng

er

on

mo

-

torc

ycle

an

d/o

r p

ati

en

t o

r p

a-

tie

nt’

s h

ou

seh

old

did

no

t o

wn

mo

torc

ycle

, b

ill p

ati

en

t’s

pe

rso

na

l

car

PIP

po

licy

Ad

dit

ion

al

If p

ati

en

t is

a m

ino

r &

pa

ren

ts

are

div

orc

ed

: p

ati

en

t ca

n p

oss

i-

bly

ma

ke c

laim

un

de

r b

oth

pa

r-

en

ts’

au

to P

IP p

olic

ies.

Bill

th

e A

uto

PIP

carr

ier

i.e

. th

e c

ar

tha

t h

it t

he

pa

tie

nt.

Se

con

da

ry

Bill

pa

tie

nt’

s a

uto

PIP

ca

rrie

r o

r th

e P

IP

insu

ran

ce o

f so

me

-

on

e in

pa

tie

nt’

s

ho

use

ho

ld.

Ad

dit

ion

al

If p

ati

en

t is

a m

ino

r &

pa

ren

ts a

re d

ivo

rce

d:

pa

tie

nt

can

po

ssib

ly

ma

ke c

laim

un

de

r b

oth

pa

ren

ts’

au

to/P

IP p

olic

y.

Pe

de

stri

an

or

Bic

ycl

e

Acc

ide

nts

PIP

In

sura

nce

Bil

lin

g G

uid

e

Sce

na

rio

: P

ati

en

t in

jure

d

an

au

to N

OT

ow

ne

d b

y

him

/he

r o

r a

no

the

r

me

mb

er

of

the

sa

me

ho

use

ho

ld

Pri

ma

ry

Bill

pa

tie

nt’

s P

IP c

arr

ier

or

PIP

ca

rrie

r co

veri

ng

the

au

to p

ati

en

t w

as

in.

Se

con

da

ry

Bill

pa

tie

nt’

s P

IP c

arr

ier

or

PIP

ca

rrie

r fo

r so

me

-

on

e in

pa

tie

nt’

s h

ou

se-

ho

ld.

Ad

dit

ion

al

If p

ati

en

t is

a m

ino

r &

pa

r-

en

ts a

re d

ivo

rce

d:

pa

tie

nt

can

po

ssib

ly m

ake

cla

im

un

de

r b

oth

pa

ren

ts’

au

to

PIP

po

licie

s.

Sce

na

rio

: P

ati

en

t a

pa

sse

ng

er

in a

n

un

insu

red

ve

hic

le

Pri

ma

ry

Bill

pa

tie

nt’

s o

wn

PIP

. I

f

pa

tie

nt

do

esn

’t o

wn

a c

ar,

or

ha

s n

o P

IP,

the

n b

ill a

PIP

po

licy

in p

ati

en

ts

ho

use

ho

ld.

Se

con

da

ry

If p

ati

en

t a

min

or

& p

ar-

en

ts a

re d

ivo

rce

d:

pa

tie

nt

can

po

ssib

ly m

ake

cla

im

un

de

r b

oth

pa

ren

ts’

au

to

PIP

po

licie

s.

Sce

na

rio

: If

pa

tie

nt

wa

s

inju

red

in h

is/h

er

ow

n

au

to o

r in

an

au

to

ow

ne

d b

y so

me

on

e in

pa

tie

nt’

s h

ou

seh

old

Pri

ma

ry

Bill

PIP

fo

r th

at

au

to.

Se

con

da

ry

If p

ati

en

t is

a m

ino

r &

pa

r-

en

ts a

re d

ivo

rce

d:

pa

tie

nt

can

po

ssib

ly m

ake

cla

im

un

de

r b

oth

pa

ren

ts’

au

to

PIP

po

licie

s.

Au

to A

ccid

en

ts

Th

e T

en

Big

ge

st M

ista

ke

s T

ha

t C

an

Wre

ck Y

ou

r W

ash

ing

ton

A

ccid

en

t C

ase

b

y C

hri

sto

ph

er

M. D

av

is,

Att

orn

ey

at

La

w

It

’s FREE

as

a p

ub

lic s

erv

ice

to

inju

red

WA

ci

tize

ns!

Ge

t yo

ur

cop

y to

da

y b

y v

isit

ing

:

ww

w.W

ash

ingto

nAccidentB

ook

.co

m

*S

om

e p

olic

ies

all

ow

yo

u t

o s

tack

th

e P

IP c

ove

rag

e (

$1

0,0

00

+ $

10

,00

0)

wh

ile o

the

rs w

ill o

nly

ext

en

d s

eco

nd

ary

co

vera

ge

in a

n a

mo

un

t g

rea

ter

tha

n t

he

pri

ma

ry a

mo

un

t. E

xam

ple

: If

th

e p

rim

ary

co

vera

ge

is $

10

,00

0 a

nd

th

e s

eco

n-

da

ry is

$2

5,0

00

, th

e m

ost

th

e s

eco

nd

ary

po

licy

will

allo

w is

$1

5,0

00

. Y

ou

sh

ou

ld a

lwa

ys r

eq

ue

st c

op

y o

f P

IP p

oli

cy t

o m

ake

su

re.

*W

ash

. la

w r

eq

uir

es

ma

nd

ato

ry P

IP c

ove

rag

e u

nle

ss t

he

po

licy

ho

lde

r re

ject

s P

IP in

wri

tin

g.

If

the

ca

rrie

r sa

ys n

o c

ove

rag

e,

alw

ays

ask

fo

r co

py

of

the

in

sure

d’s

wri

tte

n P

IP r

eje

ctio

n.

If

no

wri

tte

n r

eje

ctio

n is

pro

du

ced

, th

e c

arr

ier

mu

st o

ffe

r P

IP c

ove

rag

e —

no

exc

ep

tio

ns.

Denia

l of PIP Insura

nce M

edical C

laim

Denia

l of PIP Insura

nce M

edical C

laim

Denia

l of PIP Insura

nce M

edical C

laim

Denia

l of PIP Insura

nce M

edical C

laim

Ther

e ar

e se

vera

l rul

es t

hat

gove

rn u

nder

wha

t ci

rcum

stan

ces

an a

uto

insu

ranc

e co

mpa

ny c

an d

eny

or li

mit

a P

IP m

edic

al c

laim

.Th

ere

are

seve

ral r

ules

tha

t go

vern

und

er w

hat

circ

umst

ance

s an

aut

o in

sura

nce

com

pany

can

den

y or

lim

it a

PIP

med

ical

cla

im.

Ther

e ar

e se

vera

l rul

es t

hat

gove

rn u

nder

wha

t ci

rcum

stan

ces

an a

uto

insu

ranc

e co

mpa

ny c

an d

eny

or li

mit

a P

IP m

edic

al c

laim

.Th

ere

are

seve

ral r

ules

tha

t go

vern

und

er w

hat

circ

umst

ance

s an

aut

o in

sura

nce

com

pany

can

den

y or

lim

it a

PIP

med

ical

cla

im.

Firs

t, in

eve

ry c

ase

prio

r to

den

ying

a c

laim

for

PIP

ben

efit

s, t

he in

sura

nce

carr

ier

mus

t pr

ovid

e th

e cl

aim

ant

wit

h a

writ

ten

expl

ana-

tion

of c

over

age

unde

r th

e po

licy,

and

incl

ude

a no

tice

tha

t th

e ca

rrie

r m

ay d

eny,

lim

it o

r te

rmin

ate

bene

fits

in c

erta

in s

itua

tion

s.

Seco

nd, t

he P

IP c

arrie

r m

ay o

nly

deny

, lim

it o

r te

rmin

ate

PIP

bene

fits

if t

he t

reat

men

t is

con

side

red

eith

er (1

) not

rea

sona

ble,

(2) n

ot

nece

ssar

y, (3

) not

rel

ated

to

the

acci

dent

, or

(4) n

ot in

curr

ed w

ithi

n 3

year

s af

ter

the

acci

dent

. Th

ese

are

the

only

rea

sons

whi

ch w

ill Th

ese

are

the

only

rea

sons

whi

ch w

ill Th

ese

are

the

only

rea

sons

whi

ch w

ill Th

ese

are

the

only

rea

sons

whi

ch w

ill ju

stif

y a

deni

al o

f th

e cl

aim

.ju

stif

y a

deni

al o

f th

e cl

aim

.ju

stif

y a

deni

al o

f th

e cl

aim

.ju

stif

y a

deni

al o

f th

e cl

aim

. O

nly

one

of t

hese

fou

r re

ason

s ne

ed b

e pr

esen

t to

just

ify

a de

nial

. Th

ird, t

he P

IP c

arrie

r’s

deci

sion

to

deny

, lim

it, o

r te

rmin

ate

the

clai

man

t’s

PIP

bene

fits

mus

t be

bas

ed o

n th

e re

view

and

opi

nion

of

a m

edic

al o

r he

alth

care

pro

fess

iona

l, i.e

., a

phys

icia

n. S

peci

fica

lly, a

"med

ical

or

heal

th c

are

prof

essi

onal

" can

not

incl

ude

an in

sura

nce

com

-Sp

ecif

ical

ly, a

"med

ical

or

heal

th c

are

prof

essi

onal

" can

not

incl

ude

an in

sura

nce

com

-Sp

ecif

ical

ly, a

"med

ical

or

heal

th c

are

prof

essi

onal

" can

not

incl

ude

an in

sura

nce

com

-Sp

ecif

ical

ly, a

"med

ical

or

heal

th c

are

prof

essi

onal

" can

not

incl

ude

an in

sura

nce

com

-pa

ny's

clai

m r

epre

sent

ativ

es, a

djus

ters

, or

man

ager

s or

any

hea

lth

care

pro

fess

iona

l in

the

dire

ct e

mpl

oy o

f th

e in

sure

r. pa

ny's

clai

m r

epre

sent

ativ

es, a

djus

ters

, or

man

ager

s or

any

hea

lth

care

pro

fess

iona

l in

the

dire

ct e

mpl

oy o

f th

e in

sure

r. pa

ny's

clai

m r

epre

sent

ativ

es, a

djus

ters

, or

man

ager

s or

any

hea

lth

care

pro

fess

iona

l in

the

dire

ct e

mpl

oy o

f th

e in

sure

r. pa

ny's

clai

m r

epre

sent

ativ

es, a

djus

ters

, or

man

ager

s or

any

hea

lth

care

pro

fess

iona

l in

the

dire

ct e

mpl

oy o

f th

e in

sure

r. T

hus,

an

adju

stor

can

-no

t de

ny a

PIP

cla

im o

n hi

s or

her

ow

n, a

nd w

itho

ut t

he s

uppo

rt o

f a

med

ical

opi

nion

. Fo

urth

, the

med

ical

or

heal

thca

re p

rofe

ssio

nal r

elie

d on

by

the

carr

ier

mus

t be

cur

rent

ly

mus

t be

cur

rent

ly

mus

t be

cur

rent

ly

mus

t be

cur

rent

ly

licen

sed,

cer

tifi

ed, o

r re

gist

ered

to

prac

tice

in t

he s

ame

heal

th f

ield

or

spec

ialt

y as

the

hea

lth

licen

sed,

cer

tifi

ed, o

r re

gist

ered

to

prac

tice

in t

he s

ame

heal

th f

ield

or

spec

ialt

y as

the

hea

lth

licen

sed,

cer

tifi

ed, o

r re

gist

ered

to

prac

tice

in t

he s

ame

heal

th f

ield

or

spec

ialt

y as

the

hea

lth

licen

sed,

cer

tifi

ed, o

r re

gist

ered

to

prac

tice

in t

he s

ame

heal

th f

ield

or

spec

ialt

y as

the

hea

lth

care

pro

fess

iona

l tha

t tr

eate

d th

e in

sure

d.ca

re p

rofe

ssio

nal t

hat

trea

ted

the

insu

red.

care

pro

fess

iona

l tha

t tr

eate

d th

e in

sure

d.ca

re p

rofe

ssio

nal t

hat

trea

ted

the

insu

red.

Fi

fth,

if t

he c

laim

ant

is b

eing

tre

ated

by

mor

e th

an o

ne h

ealt

h ca

re p

rofe

ssio

nal,

the

re-

view

sha

llsh

all

shal

lsh

all b

e co

mpl

eted

by

a pr

ofes

sion

al li

cens

ed, c

erti

fied

, or

regi

ster

ed t

o pr

acti

ce in

the

sa

me

heal

th f

ield

or

spec

ialt

y as

the

prin

cipa

l pre

scrib

ing

or d

iagn

osin

g pr

ovid

er, u

nles

s ot

herw

ise

sam

e he

alth

fie

ld o

r sp

ecia

lty

as t

he p

rinci

pal p

resc

ribin

g or

dia

gnos

ing

prov

ider

, unl

ess

othe

rwis

e sa

me

heal

th f

ield

or

spec

ialt

y as

the

prin

cipa

l pre

scrib

ing

or d

iagn

osin

g pr

ovid

er, u

nles

s ot

herw

ise

sam

e he

alth

fie

ld o

r sp

ecia

lty

as t

he p

rinci

pal p

resc

ribin

g or

dia

gnos

ing

prov

ider

, unl

ess

othe

rwis

e ag

reed

to

by t

he in

sure

d an

d th

e in

sure

r. ag

reed

to

by t

he in

sure

d an

d th

e in

sure

r. ag

reed

to

by t

he in

sure

d an

d th

e in

sure

r. ag

reed

to

by t

he in

sure

d an

d th

e in

sure

r. Th

is d

oes

not

proh

ibit

the

insu

rer

from

pro

vidi

ng a

ddi-

tion

al r

evie

ws

of o

ther

cat

egor

ies

of p

rofe

ssio

nals

.

Fina

lly, t

he in

sura

nce

com

pany

’s e

xpla

nati

on f

or t

he d

enia

l of

PIP

bene

fits

mus

t be

cle

ar

enou

gh s

o th

at t

he c

laim

ant

does

not not

not

not

need

to

reso

rt t

o ad

diti

onal

res

earc

h to

und

er-

addi

tion

al r

esea

rch

to u

nder

-ad

diti

onal

res

earc

h to

und

er-

addi

tion

al r

esea

rch

to u

nder

-st

and

the

reas

on f

or t

he a

ctio

n.st

and

the

reas

on f

or t

he a

ctio

n.st

and

the

reas

on f

or t

he a

ctio

n.st

and

the

reas

on f

or t

he a

ctio

n. A

sim

ple

stat

emen

t, f

or e

xam

ple,

tha

t th

e se

rvic

es a

re

"not

rea

sona

ble

or n

eces

sary

" is

not

suff

icie

ntno

t su

ffic

ient

not

suff

icie

ntno

t su

ffic

ient

.

Da

vis

La

w G

rou

p,

P.S

. 2

10

1 F

ou

rth

Ave

., S

uit

e 6

30

Sea

ttle

, W

A 9

81

21

20

6.7

27

.40

00

Da

visL

aw

Gro

up

Se

att

le.c

om

C

hri

s D

av

is

Att

orn

ey

At

Law