SAINT BARNABAS MEDICAL CENTER A/S/O SEAN HOLEY VS. Â MERCURY INDEMNITY COMPANY OF AMERICA(L-6590-15, ESSEX COUNTY AND STATEWIDE), A-2311-15T2

On June 24, 2013 Sean Holey (insured) received outpatient burn/graft treatment at Saint Barnabas Medical Center (SBMC) and assigned PIP benefits to SBMC.
SBMC billed $10,404 for surgical and ancillary services; Mercury Indemnity Co. of America (MICA) paid $3,234.31 under the HOSF fee schedule and SBMC's PPO contract, denying ~11 ancillary line items as integral to the surgical procedure.
SBMC asserted the appropriate HOSF-allowed maximum was $6,681.02 and sought an additional $3,446.71 from MICA.
The dispute went to a Dispute Resolution Professional (DRP) and then to a three-member DRP Panel; both found MICA properly denied separate reimbursement for ancillary items and affirmed payment based on HOSF rules.
SBMC sought judicial review under APDRA (N.J.S.A. 2A:23A-1 et seq.) to vacate the award, arguing DRP erred in law and the matter raised issues of general public importance.
The Law Division (Judge Gardner) affirmed the DRP award; SBMC appealed to the Appellate Division which dismissed the appeal for lack of appellate jurisdiction under APDRA.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether appellate review is available of a Law Division order confirming an APDRA award	SBMC: appellate review is available because hospital billing practices and interpretation of N.J.A.C. 11:3-29.5 raise issues of general public importance	MICA: APDRA limits review; only rare supervisory jurisdiction exceptions permit appellate review	Court: APDRA bars further appeal except in rare supervisory circumstances; no such circumstances here, so appeal dismissed
Whether the DRP/DRP Panel erroneously applied law in disallowing ancillary charges as integral to the surgical code	SBMC: DRP misapplied HOSF rules and undervalued surgical code 15100; ancillary items should be separately reimbursable	MICA: DRP correctly applied N.J.A.C. 11:3-29.5 and HOSF fee schedule; ancillary items are intrinsic and not separately billable	Court: Did not reach merits; accepted that trial judge acted within APDRA bounds and deferred to DRP factfinding; no appellate review granted

Mt. Hope Dev. Assocs. v. Mt. Hope Waterpower Project, L.P., 154 N.J. 141 (discusses APDRA purpose and limits on review)
Morel v. State Farm Ins. Co., 396 N.J. Super. 472 (general rule: no appeal from trial court orders in APDRA matters)
Riverside Chiropractic Grp. v. Mercury Ins. Co., 404 N.J. Super. 228 (appellate supervisory review is limited to rare, nondelegable matters)
Fort Lee Surgery Ctr., Inc. v. Proformance Ins. Co., 412 N.J. Super. 99 (declining appellate jurisdiction where trial judge acted within APDRA bounds)
Selective Ins. Co. of Am. v. Rothman, 414 N.J. Super. 331 (exception: appellate review where DRP failed to enforce clear statutory mandate involving significant public concern)
Allstate Ins. Co. v. Sabato, 380 N.J. Super. 463 (appellate review permitted over attorney-fee issues as supervisory function)
Faherty v. Faherty, 97 N.J. 99 (example of appellate review over arbitrator in special circumstances)
Kimba Med. Supply v. Allstate Ins. Co., 431 N.J. Super. 463 (invoking exception to clarify APDRA interpretation and trial court remand powers)
N.J. Citizens Underwriting Reciprocal Exch. v. Kieran Collins, D.C., LLC, 399 N.J. Super. 40 (dismissing appeal where trial court stayed within limited APDRA review)