A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL

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1 CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z v. INS. CO. CLAIMS NO.: N N44 Colonial Penn Insurance Co DRP NAME: James H. Garrabrandt (Respondent) NATURE OF DISPUTE: Non-Payment of Bill AWARD OF DISPUTE RESOLUTION PROFESSIONAL I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP), designated by the American Arbitration Association under the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New Jersey Automobile Insurance Cost Reduction Act as governed by N.J.S.A. 39:6A-5, et. seq., and, I have been duly sworn and have considered such proofs and allegations as were submitted by the Parties. The Award is DETERMINED as follows: Injured Person(s) hereinafter referred to as: Assignor. 1. ORAL HEARING held on February 3, ALL PARTIES APPEARED at the oral hearing(s). NO ONE appeared telephonically. 3. Claims in the Demand for Arbitration were NOT AMENDED at the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made by the parties regarding the issues to be determined (Stipulations, if any, set forth below). 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: This matter arose out of an automobile accident that occurred on March 3, 2000 and is, therefore, subject to AICRA. Assignor underwent a course of TMJ treatment with Claimant, Dr. Stuart Katz (hereinafter referred to as "Claimant", or "Dr. Katz"). Dr. Katz submitted a bill for services rendered and itemized as follows:

2 CASE NO. 18 Z For date of service July 1, 2002, Dr. Katz billed $ under CPT for an office visit; $75.00 under CPT for an orthopantogram and $10.00 under CPT for educational supplies (TMJ pamphlet). On August 6, 2002, Dr. Katz billed his usual and customary fee of $1, under CPT for a TMJ appliance and $45.00 under CPT for an office visit. EOB's show that Respondent paid $75.00 for the orthopantogram performed on Assignor on July 1, 2002 and following application of the prevailing medical fee schedule, paid $39.12 for the office visit conducted on August 6, For date of service July 1, 2002, Respondent denied payment of (i) CPT indicating that "[f]urther documentation required. Return EOB & bill with documentation to Concentra" and CPT as a "[n]on covered item." For date of service August 6, 2002, Respondent denied payment of CPT indicating that "[f]urther documentation required. Return EOB & bill with documentation to Concentra." Respondent contends that this is not a complicated matter; it is simply a denial based upon claimant's failure to provide verification of treatment under N.J.S. 39:6A-5(b). N.J.S. 39:6A-5(b) provides that "For purposes of this section, notification shall be deemed to be met if a treating health care provider submits a bill or invoice to an insurer for reimbursement of services within 21 days of the commencement of treatment." Respondent's reliance upon N.J.S. 39:6A-5(b) is misplaced. Notification of commencement of treatment was not argued as a defense, or raised as an issue by Respondent in this case. There are three issues in this case. The first issue in this case is whether Dr. Katz furnished sufficient documentation to Respondent to be paid for services rendered to Assignor on July 1, 2002 and August 6, 2002 and billed under CPT and CPT 21110, respectively. Consideration has been given to an Affidavit dated March 14, 2003 and signed by M... L..., a Claims Examiner for Respondent, and submitted as evidence on behalf of Respondent in this case. M... L... contends that Concentra, the no-fault claims administrator for Respondent, had insufficient information regarding Assignor's treatment and, therefore, Respondent was unable to verify and evaluate Dr. Katz' claim. In addition, M... L... states that following his receipt of the Demand for Arbitration, he contacted Claimant's counsel and requested

3 CASE NO. 18 Z copies of Dr. Katz' records and a narrative report regarding Assignor's treatment. He made numerous requests for those records and narrative report and, finally, on January 30, 2003, Claimant's counsel faxed the requested documents to him. Upon reviewing Dr. Katz' records, M... L... advised Claimant's counsel that he would forward payment for the doctor's services in accordance with the New Jersey fee schedule. He would not, however, pay any attorney's fees. As gleaned from a Certification dated March 20, 2003 and signed by Dr. Katz and various supporting documentation of record in this case, Assignor was first seen by Dr. Katz on July 1, 2002 and was complaining of jaw pain causing migrane headaches; bilateral clicking in her jaw and pain on palpation of the sternocleidomastoid, occipital, temporalis, masseter and medial pterygoid muscles. The maximum interincisal opening had deviation to the left, and bilateral TMJ pain. Those clinical findings were set forth in a request for pre-certification of a TMJ appliance, x-rays and office visits dated July 2, 2002 and faxed to Concentra/Respondent on July 3, A copy of the fax transmittal confirmation report is of record in this case. Dr. Katz states that the request for pre-certification was granted. Upon receiving the EOB's from Concentra/Respondent requesting further documentation for his billing under CPT and CPT 21110, Dr. Katz furnished Concentra/Respondent with copies of his office treatment notes for dates of service July 1, 2002 and August 6, Copies of Dr. Katz' records were furnished to Concentra/Respondent prior to the filing of the Demand for Arbitration. The Re-evaluation Treatment Plan (Decision Point Review)/request for pre-certification of TMJ appliance, x-rays and office visits dated July 2, 2002, with office treatment notes for date of service dated July 1, 2002 attached thereto and faxed to Concentra/Respondent on July 3, 2002 and the office treatment notes for dates of service July 1, 2002 and August 6, 2002 sent to Concentra/Respondent following Dr. Katz' receipt of the EOB's from Concentra/Respondent constitute sufficient documentation to establish the nature and extent of the treatment rendered to Assignor on the subject dates of service. Clearly, then, and despite Respondent's contention to the contrary, Concentra, the nofault claims administrator for Respondent, had sufficient information regarding Assignor's treatment prior to the filing of the Demand for Arbitration for Respondent to verify and evaluate Dr. Katz' claim. Respondent's denial of payment for CPT and CPT was, therefore, improper. The second issue in this case is whether Claimant should be reimbursed for billing $10.00 under CPT for providing Assignor with a TMJ pamphlet on date of service July 1, 2002.

4 CASE NO. 18 Z Respondent denied payment of CPT as a "[n]on covered item." Respondent did not, however, provide any authoritative documentary evidence in support of its denial of payment of CPT Respondent's denial of payment for CPT was, therefore, improper. Claimant is entitled to reimbursement of the fee schedule charge of $ for the office visit conducted on July 1, 2002 and billed under CPT 99244; his UCR charge of $10.00 for the TMJ pamphlet billed under CPT on date of service July 1, 2002 and his UCR charge of $1, for the TMJ appliance billed under CPT on date of service August 6, Claimant is entitled to reimbursement in the amount of $1, Medical expense benefits are awarded as outlined hereinabove and set forth in Paragraph 5, below. Interest is awarded in the amount of $ The third issue is whether Claimant's counsel is entitled to attorney's fees and costs in this matter. N.J.A.C. 11:3-5.6(d)3 provides that the decision of the dispute resolution professional "may include attorney's fees for a successful claimant in an amount consonant with the award and with Rule 1.5 of the Supreme Court's Rules of Professional Conduct." Claimant has prevailed and, therefore, Claimant's counsel is entitled to attorney's fees in this matter. RPC 1.5 provides, in pertinent part, that (a) A lawyer's fee shall be reasonable. The factors to be considered in determining the reasonableness of a fee include (1) the time and labor required, the novelty and difficulty of the questions involved, and the skill requisite to perform the legal service properly;... (3) the fee customarily charged in the locality for similar legal services; (4) the amount involved and the results obtained; (5) the time limitations imposed by the client or by the circumstances;... (7) the experience, reputation, and ability of the lawyer or lawyers performing the services;... An award of attorney fees of $1, is consonant with the amount of the Award and in keeping with the guidelines of RPC 1.5. Claimant's counsel seeks costs in the amount of $ (filing fee for AAA - $325.00).

5 CASE NO. 18 Z N.J.A.C. 11:3-5.6(d)2 provides that "the award shall apportion the costs of the proceedings, regardless of who initiated the proceedings, in a reasonable and equitable manner consistent with the resolution of the issues in dispute." Consistent with N.J.A.C. 11:3-5.6(d)2, costs are awarded in the amount of $ and are to be paid to counsel of record for Claimant. 5. MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to Dr. Stuart Katz $1, $1,378.68* Dr. Stuart Katz Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. *Subject to the prevailing medical fee schedule, Claimant's usual and customary charges and any deductible and co-payments. 6. INCOME CONTINUATION BENEFITS: Not In Issue 7. ESSENTIAL SERVICES BENEFITS: Not In Issue 8. DEATH BENEFITS: Not In Issue 9. FUNERAL EXPENSE BENEFITS: Not In Issue 10. I find that the CLAIMANT did prevail, and I award the following COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A. 39:6A-5h. (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $ (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1, (C) INTEREST is as follows: Awarded in the amount of $41.36.

6 CASE NO. 18 Z