Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) MRI Thoracic Spine without contrast prior authorization requirements (2026)
What Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) generally requires to approve MRI Thoracic Spine without contrast (CPT 72146), for Auto No-Fault (NJ PIP) plans. Yes. Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) generally requires prior authorization for MRI Thoracic Spine without contrast (CPT 72146).
Medical-necessity criteria Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) generally applies
Decision point review (DPR) required: MRI is on the N.J.A.C. 11:3-4.5(b) diagnostic-test list, so the determination to administer it is a decision point for ALL injuries, not just Care Path injuries (11:3-4.5(d)). Per 11:3-4.5(b)5, MRI use should conform to ACR Appropriateness Criteria and is not normally performed within 5 days of the insured event absent red flags (e.g., gross motor deficits, incontinence, acute nerve-root compression). No DPR or precertification applies to emergency care or within 10 days of the accident (11:3-4.7(b)) - medical necessity and causation still apply. Submit the DOBI Uniform APTP form with clinically supported findings from a personal examination; the carrier must respond within 3 business days (11:3-4.7(c)4), and under DOBI-approved plans treatment is deemed authorized until a determination issues if it fails to respond timely. Failure to request DPR where required risks a co-payment penalty of up to 50% of the eligible charge (11:3-4.4(e)); using a non-network facility where the plan has an approved voluntary network for MRI can add a penalty of up to 30% (11:3-4.4(g), 11:3-4.8(b)). Spine soft-tissue and disc-herniation injuries (identified injuries) also follow the DOBI Care Paths (11:3-4.6).
Commonly required documentation
- DOBI Uniform Attending Provider Treatment Plan (APTP) form ver. 16.03.10 (nj.gov/dobi/pipinfo/aptp_ver160310.pdf) - patient name/DOB, claim number, date of accident, ICD-10 codes, each CPT code with frequency/duration, provider signature
- clinically supported findings from a personal physical examination
- relevant progress notes and prior imaging/test results. Incomplete APTPs are denied as deficient.
How to submit
- Method: Fax APTP 732-978-7100 (phone 888-814-6397)
- Portal: Plymouth Rock
- Typical turnaround: about 3 days
Sources & verification
NJ PIP (auto no-fault). Sources: N.J.A.C. 11:3-4 (eff. 10/16/2017), carrier DPRP: https://www.plymouthrock.com/public/Plymouthrock/StaticFiles/PDF/Decision-Point-Review-Plan-edition-PRA-NJ-203-04-22.pdf; OSSNJ no-fault pre-cert reference table (photographed 2026-06-25). Internal appeal required before PIP arbitration (11:3-4.7B): pre-service within 30 days of denial (decision due 14 days), post-service at least 45 days before ADR (decision due 30 days), on DOBI uniform appeal forms. IME: must be scheduled within 7 calendar days, same-discipline examiner, decision 3 business days after exam (11:3-4.7(e)). Statewide facts verified 2026-07-09. Includes High Point, Palisades, Teachers, Twin Lights. Post-service appeals fax 732-978-6320. [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) require prior authorization for MRI Thoracic Spine without contrast?
Yes. Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) generally requires prior authorization for MRI Thoracic Spine without contrast (CPT 72146).
What does Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) require to approve MRI Thoracic Spine without contrast?
Decision point review (DPR) required: MRI is on the N.J.A.C. 11:3-4.5(b) diagnostic-test list, so the determination to administer it is a decision point for ALL injuries, not just Care Path injuries (11:3-4.5(d)). Per 11:3-4.5(b)5, MRI use should conform to ACR Appropriateness Criteria and is not normally performed within 5 days of the insured event absent red flags (e.g., gross motor deficits, in… Always confirm against the current Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) policy.
How long does a Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) prior authorization take?
Plymouth Rock (High Point, Palisades, Teachers, Twin Lights) typically decides MRI Thoracic Spine without contrast requests in about 3 days. Timeframes vary; check the payer portal.
Submitting MRI Thoracic Spine without contrast to Plymouth Rock (High Point, Palisades, Teachers, Twin Lights)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.