NJDA's Council on Peer Review is responsible for oversight and administration of the system, while local peer review committees conduct the actual review. The council is composed of a chairman and one member from each of the twelve component dental societies, as well as each of the specialty societies. The council's duties include setting policy standards for the individual peer review committees and hearing appeals of the committee decisions. Administrative duties involved with each case are performed by the council staff at the NJDA headquarters.

Each component society has a peer review committee to review cases involving general dentists in its component area. Disputes concerning specialists are referred to the appropriate committee.

REQUESTING MEDIATION

When a Request for Mediation is received by council staff at NJDA, a case number is assigned and necessary preliminary information is compiled, including the signed consent forms. The case is then forwarded to the appropriate peer review committee chairman who may decide that mediation is appropriate. If that is the case, the appointed mediator contacts all parties and attempts to reconcile their differences. In a mediation, the patient is not the examined nor is any conclusion reached as to the validity of the complaint.

IF MEDIATION IS UNSUCCESSFUL

If mediation is not successful, the mediator informs the chairman that action by the entire peer review committee is warranted. The chairman then appoints at least three members of the committee to review all aspects of the case for a hearing. A hearing may be either the "summary" or "plenary" type. In the summary hearing, the committee will consider only records and other written information that has been gathered. In the plenary hearing, the party initiating the complaint and the party against whom the complaint has been lodged are given the opportunity to attend the hearing and present testimony. The patient may be examined by the committee at this time. The committee then will meet separately to discuss its findings and prepare a final report. The report is sent to council staff at NJDA, who will summarize the committee's decision and forward it to both parties.

ONCE A DECISION IS REACHED

When the committee finds in favor of the dentist, the patient and/or carrier will be directed to pay any outstanding balance owed to the dentist. When the committee finds in favor of a patient or insurance carrier, the dentist may be directed to adjust or redo the treatment, provided that the patient is willing to return. If not, the committee may direct the dentist to return all or a portion of the fees paid for the treatment in question. In no event will the amount of refund be greater than the total fees paid.

IF YOU WOULD LIKE TO APPEAL

Either party may appeal the committee's decision within 30 days of receipt of the decision letter. An appeal must be based on one of the following criteria:

• Proper procedure was not followed.
• New material information is available which was not previously considered.
• The decision runs counter to the evidence and testimony presented.

Appeals of decisions that direct either the return of fees or the payment of an outstanding balance must be accompanied by a certified check, payable to NJDA in the amount of the decision. These funds will be held in escrow until after the appeal has been heard or request for appeal denied. Appeal requests are reviewed by a subcommittee of the Council on Peer Review. If the subcommittee decides an appeal is warranted, it has the option of remanding the case to the original committee for the further consideration, appointing a new committee, or referring the case to the Council.

• Peer Review will not accept cases if legal action is in process or if a complaint has already been submitted to the New Jersey State Board of Dentistry.
• Attorneys may not represent either party in the peer review process.
• Peer review is available to all New Jersey dentists, whether or not they are members of NJDA, as long as the request is initiated by a patient.
• Only NJDA members may submit disputes with an insurance carrier.
• The committee may terminate a review if either party does not cooperate fully. Non-cooperation includes but is not limited to a patient’s failure to appear at a scheduled clinical examination, or a dentist’s failure to forward.
• In certain instances, the committee can determine that no decision is possible due to insufficient available evidence. This determination does not necessarily indicate an approval or disapproval of the treatment that was rendered.
• All monetary awards are handled through NJDA’s Peer Review Escrow Account. In cases where monies are to be returned to the patient, NJDA will obtain a signed release form, which will be subsequently sent to the dentist.
• Committees cannot request monies be paid for future treatment or for pain and suffering.
• Peer review will not review cases that involve fee disputes or the appropriateness of fees. The contents of all peer review cases are kept in the strictest of confidence.
• A patient has two (2) years from the date of the service at issue to file a complaint.