Is the Uniform Attending Provider Form required to be used for all PIP claims?
No, the Uniform Attending Provider Form is to be used to make Decision Point Review and Precertification requests required by the Department’s Protocols rule, N.J.A.C. 11:3-4 and individual insurer Decision Point Review Plans. It replaces the forms used by individual insurers.

There are two links to the Form on the Department’s web site. What is the difference?
The Department has put the form on its web site as a PDF, that is the type of file used with the Adobe Acrobat program, which can be downloaded for free. Acrobat files are images and therefore retain the exact format of the document as it was created and are often used with forms. The form was created in Microsoft Excel and is also available in that file format (.xlsx).

There are only four spaces provided for diagnoses and four spaces for CPT codes or ranges of codes. What if a patient has more than four diagnoses or the provider wants to request more codes?
The provider can put additional diagnoses or codes on an attachment to the form or attach another copy of the form and only fill in the additional information that does not fit on the first form. Physical medicine providers may be able to make their requests fit on the form by using the ranges of CPT codes that the form permits. However, it is not appropriate to put a range of codes on the form that include codes that the provider does not intend to use. For example, some providers put all the Modality codes, 97010 through 97546, as the range. Since the provider isn’t going to perform all 31 procedures represented by the codes, this does not give the payor the information necessary to determine if the proposed treatment is medically necessary.

Can the Uniform Attending Provider Form be submitted by a DME provider with a note from the treating physician or chiropractor concerning the medical necessity of the equipment?
Although a DME vendor is defined as a provider in N.J.A.C. 11:3-4, it was not the intention of the Department that DME vendors submit the Uniform Attending Provider Form to payors. DME vendors don’t treat patients or make diagnoses. The attending provider needs to set forth the diagnosis(es) and clinically supported findings on the Uniform Attending Provider Treatment Form and sign the form with its Statement and Fraud Prevention Warning. The DME vendor or other non-treating provider can then provide the equipment or services that have been determined to be medically necessary.

No spaces on the form are provided for co-morbidities/treatment complications that are relevant to a Decision Point Review or Precertification request. How should this be handled by providers?
The Uniform Attending Provider Form is not intended to include ALL the information that is submitted with a Decision Point Review or Precertification request. It should be accompanied by SOAP notes, test results and other information related to the request, including how co-morbidities or treatment complications that affect the treatment or testing requested.

In Box #35, the patient is asked if they have ever had any of a list of services. Does this mean since the accident occurred or all such information whether it is related to the injuries sustained in the accident or not?
Box #35 is intended to capture the information that a provider takes as part of the patient history before providing treatment and covers both before and after the accident. Thus, whether a 55-year-old patient who had had back surgery prior to an accident resulting in a back injury would be relevant to the treatment being recommended, while a tonsillectomy at age 12 probably would not.

What is the Diagnosis Pointer column in Box 38?
In box#36 of the APTP,  the diagnosis codes will entered on lines A through L. In the column titled “Diagnosis Pointer” in Box #38, the letter corresponding to the line with the relevant diagnosis in box #36 should be entered. This provides the carrier/vendor with information so they can clinically relate the requested service (CPT/HCPCS code) to the primary diagnosis. When multiple services are being requested the primary reference letter for each diagnosis should be listed first with other applicable diagnoses following, up to a maximum of four. The above would apply to either ICD-9 or ICD-10 codes. See example below.

The Uniform Attending Provider Form mandated by Order A16-101 that is on the Department’s web site is in red type. Is red type mandatory?
No, the red type is used in some scanning applications. Insurers and providers can make the print on the form black or red.

Our insurance company would like to add specific company contact information to the form, is this permissible?
The Department would prefer that insurers not make any substantive additions to the form attached to the Order. In any case, no insurer may refuse to accept the generic Form.

In section 42, if a provider enters a range of codes (example 12345 through 12348) and total units equaling 24, does this mean that they get 24 units of each code in the range (example: 24 units of 12345 and 24 units of 12346 and 24 units of 12347, etc.) during the treatment date range in section 40?
No, if a range of codes is provided, the number of units cannot exceed the total requested for any combination of the codes in the range. (For the example above: 4 units of 12345; 4 units of 12346, 4 units of 12347 and 4 units of 12348 equals 24 units total.) If a provider wants 24 units for each code, he or she would have to list each code in the left box only (as explained on the form) and put 24 units for each code on a separate line.