Plymouth Rock Claims FAQs

If you need to locate a doctor, simply click here

If you need to locate a pharmacy, simply contact our network vendor, Mitchell Script Advisor or 866-221-6588; or Optum at 877-494-9195.

Your medical bills should be sent to:
Plymouth Rock Assurance
PO Box 900
Lincroft, NJ 07738-0900

For your convenience, a self-addressed envelope will be provided in your initial PIP Package. Please put your claim number on the envelope and on the medical bills themselves so that we can promptly direct your bills to your claims representative.

If you have chosen your health carrier as primary, please be sure to submit all medical bills to your health insurer first. If there are any outstanding balances remaining after your health carrier has processed your bills as primary, please send us a copy of their Explanation of Benefits (EOB) along with a copy of the corresponding bill(s). You may also fax your medical bills to 732-978-7109. If you are sending your bills by fax please be sure to write your claim number on a cover sheet or on the bill itself to ensure that the bill is directed to the correct claims representative.

It is important to report any accident to us as soon as possible. There are several ways you can report your claim. Our First Report Unit can be reached toll-free 24/7 at 800-437-3535. You can also report your claim online. If you have an agent, you may ask that he or she report the claim for you.

Failure to comply with prompt notice may result in a reduction of reimbursement (co-payment penalty) of eligible charges for medically necessary expenses that are incurred after notification to us is required and until notification is received. This requirement applies at all times unless the eligible injured person submits written proof providing clear and reasonable justification for the failure to comply with such time limitations.

Reporting Timeframe
Loss reported 31-60 days after accident
Loss reported 61 or more days after accident

Copayment Penalty
25% Penalty
50% Penalty

The Statute of Limitations on PIP claims in the State of New Jersey requires that an action for benefits be filed not later than two years after the injured person suffers a loss or incurs an expense caused by the accident, or not later than four years after the accident, whichever is earlier, provided that if benefits have been paid before then, an action for further benefits may be commenced not later than two years after the last payment of benefits.

The State of New Jersey enacted regulations to ensure that you receive the appropriate level of quality care for your injuries. For this reason, we encourage your health care provider to contact us and agree to a comprehensive treatment plan, including any medications prescribed. If precertification is required and not obtained, we may impose a penalty against the provider on services that are medically necessary, but not precertified. Your provider is not permitted to bill you for the amount of the penalty.

These requirements apply at all times, except when the medically necessary treatments or care, medical services and medical transportation are provided within the first ten days following the covered accident or when administered during emergency care.

For a complete copy of our Precertification and Decision Point Review Plan, click here.

Review the applicable Decision Point Review Plans to determine what services need pre-certification.

A PIP Claims Representative will contact you to discuss your injuries and also to get the names of any health care providers you may be seeing. It is important that we have this information so that we can maintain contact with your providers regarding your treatment. In order for us to process your claim, you must complete the Application for Benefits – Personal Injury Protection form, which we will send to you, along with a copy of this notice, when you report a claim involving personal injury. You may also find a copy of the Application for Benefits here.

It is also a good idea for you to share this information with all of your health care providers, as they will be responsible for adhering to the Decision Point Review and Precertification requirements and regulations. Each provider will be responsible for submitting the Notification of the Commencement of Treatment form, which is also sent to you when you report a claim involving personal injury.

A person seeking any coverage must:

• Cooperate with us in the investigation of any accident or loss.
• As soon as reasonably practicable, give or send us copies of any notices or legal papers sent or received in connection with the accident or loss.
• Submit as often as we require, to physical and mental exams by physicians we select.
• Submit to exams under oath as often as we reasonable request and must take place within 30 days of our request.
• Provide us, as we reasonably request with signed statements and recorded statement.

A higher benefit of coverage is available in-network. Because our payments to an in-network provider are generally less than those paid to an out of network provider, your medical expense benefits are depleted at a slower rate. In addition, failure to schedule the appointment through the Voluntary Network or to utilize the Voluntary Diagnostic Network will result in an additional 30% copayment of the eligible charges that are incurred for medically necessary tests, equipment, and procedures listed below.

Eligible injured persons will be referred to our approved Voluntary Networks for specific diagnostic testing, durable medical equipment, and outpatient services. You can find a list of participating doctors and facilities through our Signature Medical Concierge Program.

PIP is your medical coverage for injuries you sustain in an auto accident. PIP is sometimes called “no-fault” coverage because it pays your own medical expenses regardless of who caused the accident. PIP has two parts:

Coverage for the cost of treatment you receive from hospitals, doctors, and other medical providers, and any medical equipment that may be needed to treat your injuries.

Depending on the coverage that was selected, reimbursement for other expenses you may have, such as income continuation or essential services.

In the State of NJ, regardless of fault, each injured person must go back to their own auto insurance policy for medical coverage. For example, if you are injured in an accident that is not your fault, your medical bills are still handled by your own insurance company, not by the insurance company of the at-fault driver. Even if you are injured in someone else’s car, your own auto insurance would be responsible for paying your medical bills.

When you treat with a New Jersey medical provider, you are not required to pay any charges that are in excess of the New Jersey Fee Schedule. No health care provider may demand or request any payment from any person in excess of those permitted by the Fee Schedule (N.J.A.C. 11:3-29), and no person is liable to any health care provider for any amount of money which results from the charging of fees in excess of that fee schedule (N.J.A.C. 11:3-29 pursuant to N.J.S.A. 39:6A-4.6).

You are, however, responsible for any unpaid amounts due to the application of the deductible and/or copayment. If you receive a bill from a health care provider for a balance due (with the exception of the amounts applied toward your deductible/copayment), contact your Claims Representative.

New Jersey law states that all insurance carriers have 60 days (calculated from the date the bill is received) to process your medical bills. However, if for any reason Plymouth Rock requires additional information prior to making a payment decision, we may request an extension not to exceed an additional 45 days (105 days total). If we require additional information from you prior to making a payment decision, you will be contacted by your Claims Representative by phone and/or by mail. If we require additional information from your medical provider, we will request that required information in writing.

Our Signature Medical Concierge Program is a voluntary medical network you can utilize for the highest level of coverage under your policy.

If you receive a statement in the mail from Plymouth Rock related to your PIP claim, it is called an Explanation of Benefits (EOB). You will receive an EOB from Plymouth Rock every time we process a medical bill related to your claim. The EOB contains important information about that particular bill, including the name of the medical provider, the amount that they billed, and the procedures they performed.

It is very important to review the EOB for accuracy. If your EOB shows that a medical provider has billed for any service(s) that were not provided, please notify your Claims Representative immediately.

The EOB will also show what Plymouth Rock paid to that medical provider and any amounts applied toward your deductible and/or copayments that you may be responsible for. In some cases, if someone else was at fault for the accident, you may be able to recover your out-of-pocket expenses from their insurance company.

If you need to locate a diagnostic facility, simply click here.

In 1988, the State of New Jersey introduced mandatory PIP deductibles and copayments. These provisions apply regardless of who is at fault for the accident. This is why PIP coverage is sometimes referred to as “no-fault” coverage. Any unpaid amounts due to the application of the deductible and/or copayment can be submitted to your health carrier for consideration, along with a copy of the Explanation of Benefits (EOB). The EOB outlines the amount the provider charged, the amount allowed under the NJ Fee Schedule, the application of the deductible/copayment, and the amount Plymouth Rock paid.

The deductible you selected will determine your total out-of-pocket expense. Remember, you can submit these expenses to your health carrier for consideration. If someone else was at fault for the accident, you may be able to recover your out-of-pocket expenses from their insurance company. Click here to view Statutory Deductibles and Copayments.

Due to the Federal Reporting requirements under the Medicare Secondary Payor Act, Plymouth Rock needs to secure Social Security Numbers for each injured person to fulfill this Federal Reporting Requirement. We cannot process any PIP claims without first reporting your Social Security Number to meet the federal requirements.

Yes, if selected, you may have Extended Medical Expense Benefits, Income Continuation Benefits and/or Essential Service Benefits. Please refer to your policy for specific information.