Navigating The “Healthcare Key” Option in PIP Claims

Navigating The “Health Care Primary” Option in PIP Claims
Navigating The “Health Care Primary” Option in PIP Claims

The function of this post is to aid assist those with inquiries they have concerning their company or medical technique. The Callagy Regulation team is experienced in numerous regulation practice locations as well as will frequently post topics varying from Medical Revenue Recuperation, PIP, Workers Compensation, as well as Commercial Insurance coverage. We want to have this blog dropped a light on several common inquiries.


As a PIP lawsuits attorney, I often locate myself describing what PIP is to people who are not knowledgeable about this location of technique. I generally describe it by specifying that injuries endured in vehicle crashes are covered by automobile insurance coverage in the state of New Jersey as well as I stand for health care suppliers in situations where the vehicle carrier denies repayment. A follow-up question I occasionally receive is, “why aren’t those injuries covered by health insurance?”

The response to this question is basic, other than when it isn’t really. (I child.) New Jersey mandates that all vehicle insurance plan cover a minimum of $15,000 of PIP insurance coverage. Usually, the automobile insurance company is the primary payor of injuries suffered in a vehicle mishap under this PIP requirement. Hence, in such cases, it is the automobile insurance company that is mainly accountable as well as not the individual’s health and wellness insurance company.

However, there is an exception to the default system which is called “medical primary.” This describes instances where the guaranteed, in choosing her car insurance coverage, chooses the “health care key” alternative. Basically, in choosing this option, the insured is committing to use medical insurance as the main payor of injuries suffered in auto accidents in exchange for a lower automobile insurance policy premium. In such cases, the individual’s auto insurance coverage functions as a secondary payor as opposed to as the main payor.

Medical main policies could place a wrinkle in healthcare suppliers’ typical billing techniques for PIP cases as well as it is beneficial to comprehend how you can browse this circumstance. If a service provider relieves a vehicle accident victim with a “healthcare key” car plan, the service provider must initially announce the client’s health insurance company. (If the service provider erroneously announces the vehicle insurance provider initially, the vehicle insurer will likely deny the claim and also the supplier can simply bill the wellness insurer afterwards.)

The inquiry then becomes, just what takes place if the patient’s wellness insurer refutes the case? Fortunately below is that the supplier could usually announce the individual’s car plan complying with such a rejection given that the PIP stipulation of the policy remains to serve as second insurance coverage.

While there is some ambiguity on this issue, numerous interpret the legislation in a manner that calls for the patient’s health and wellness insurance company to issue a substantive denial in order for PIP to be activated as second protection.

For instance, if the wellness insurer denies the claim since the therapy is not covered under the person’s policy, this would certainly work as a substantive rejection and the provider would after that be free to tout the client’s auto insurance company. Nonetheless, if the health insurer rejects the case specifying that even more paperwork is needed to process the case, this will likely not be regarded as a substantive denial and also the service provider would certainly be smart to resubmit the claim to the health insurer with the asked for documents prior to trying to bill the client’s auto provider.

One last note to be conscious of is, when touting the car provider complying with a medical insurance denial, make certain to include the medical insurance EOBs. This will indicate to the automobile carrier that, despite the fact that the case includes a healthcare primary plan, the individual’s health and wellness insurance provider was already announced but the case was denied.


We hope you found the details supplied in this post helpful to various questions you could have had concerning the medical care market. For information concerning our services for clinical providers, please go here. Please note, Callagy Legislation has actually recuperated over $200,000,000 for clinical providers, and that number grows daily. Our team of educated PIP Settlement lawyers are ready in order to help you. Please free to reach out to Sean Callagy of Callagy Legislation any time for inquiries you might have worrying individual as well as business issues. Callagy Regulation workplaces lie comfortably in Paramus, NJ. Past the extent of details, Sean Callagy has established several areas of our health care lawful method and also business coaching. Don’t hesitate to connect with us on Facebook, Twitter or LinkedIn! Furthermore you could register for our day-to-day videos on YouTube.


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