New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 1 - PROMPT PAYMENT OF CLAIMS › Section 11:22-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
"ADR" or "alternative dispute resolution" means any procedure, other than litigation, used in the conciliatory resolution of a dispute, including, but not limited to, mediation and arbitration, but shall not include claims payment dispute arbitration pursuant to P.L. 2005, c. 352.
"Agent" means an entity contracted by or affiliated with a carrier to perform administrative functions including, but not limited to, the payment of claims or the receipt, processing, or transfer of claims or claim information, such as an organized delivery system (ODS) as defined at
17:48H-1
et seq., or a third-party administrator (TPA) as defined at
17B:27B-1
et seq.
"Arbitration" means the process of determining a payment dispute pursuant to P.L. 2005, c. 352, between a health carrier and a provider by one or more impartial persons in a final and binding determination.
"Arbitration organization" means the nationally recognized, independent organization with which the Department of Banking and Insurance has contracted for the purpose of conducting payment arbitrations and making determinations in accordance with the requirements of this subchapter.
"Arbitrator" means an individual employed by, or under contract with, the arbitration organization who is responsible for conducting payment arbitrations and making determinations in accordance with the requirements of this subchapter.
"Capitation payment" means a periodic payment to a health care provider for his services under the terms of a contract between the provider and a carrier, under which the provider agrees to perform the health care services set forth in the contract for a specified period of time for a specified fee, but shall not include any payments made to the provider on a fee-for-service basis.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, a dental service corporation or dental plan organization authorized to issue dental plans in this State, and a prepaid prescription service organization.
"Commissioner" means the Commissioner of Banking and Insurance.
"Claim" means a request by a covered person or a provider for payment of benefits under a policy or contract issued by a carrier for which the financial obligation for the payment of a claim under the policy or contract rests in whole or in part with the carrier.
"Clean claim" means:
1. The claim is for a service or supply covered by the health benefits plan, prescription drug plan, or dental plan;
2. The claim is submitted with all the information requested by the carrier on the claim form or in other instructions distributed to the provider or covered person in accordance with
17B:30-51
and
11:22-1.4
;
3. The person to whom the service or supply was provided was covered by the carrier's health benefits, prescription drug, or dental plan on the date of service;
4. The health care provider providing the service or supply is an eligible provider on the date of service (that is, a health care provider whose services or supplies are covered under the health benefits, dental, or prescription drug plan); and
5. The carrier does not reasonably believe that the claim has been submitted fraudulently.
"Covered person" means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits or dental plan.
"Covered service or supply" means a service or supply provided to a covered person under a health benefits or dental plan for which the carrier is obligated to pay benefits or provides services or supplies.
"Dental carrier" means a dental service corporation, dental plan organization, health service corporation, medical service corporation, and insurance company authorized to issue dental plans in this State.
"Dental plan" means a benefits plan that pays benefits only for dental expenses or provides only dental services and supplies and is delivered or issued for delivery in this State by or through any dental carrier in this State.
"Department" means the Department of Banking and Insurance.
"Explanation of benefits" or "EOB" means a document a carrier issues to a covered person in response to the submission of a claim for services or supplies under a health benefits plan. The EOB identifies both the billed and allowed charges and explains whether services and supplies are covered, the application of cost sharing, the amount paid by the plan, and the reason(s) for any denials or reductions in the benefits paid.
"Health benefits plan" means a benefits plan which pays hospital and medical expense benefits or provides hospital and medical services, and is delivered or issued for delivery in this State by or through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage and Medicare Advantage to the extent not otherwise prohibited by Federal law. For the purposes of this chapter, health benefits plan shall not include the following plans, policies, or contracts: accident only, credit, dental plans, disability, long-term care, CHAMPUS supplement coverage, Tri-Care, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to
39:6A-1
et seq., or hospital confinement indemnity coverage.
"Health care provider" or "provider" means an individual or entity which, acting within the scope of its license or certification, provides a covered service or supply as defined by the health benefits or dental plan. Health care provider includes, but is not limited to, a physician, dentist and other health care professional licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.
"Health carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization authorized to issue health benefits plans in this State, and a prepaid prescription service organization.
"Medical necessity" or "medically necessary" means or describes a health care service that a health care provider, exercising his or her prudent clinical judgment, would provide to a person covered by a health benefits plan for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the covered person's illness, injury, or disease; not primarily for the convenience of the covered person or the health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person's illness, injury, or disease. Medical necessity disputes do not include claims payment disputes.
"Network provider" or "participating provider" means a health care provider who has entered into a contract with a carrier to provide health care services or supplies to covered persons for a predetermined fee or set of fees.
"Organized delivery system" or "ODS" means an organized delivery system that is either certified or licensed pursuant to N.J.S.A. 17:48H-1 et seq.
"Payment dispute" means a disagreement between a health carrier and provider over whether a claim was properly paid under the terms of the applicable health benefits plan and provider participation agreement, if applicable. A payment dispute shall not include a dispute pertaining to medical necessity that could be or could have been submitted to the Independent Health Care Appeals Program established pursuant to
26:2S-11
.
"Prepaid prescription service organization" means any prepaid prescription service organization issued a certificate of authority pursuant to
17:48F-1
et seq.
"Prescription drug plan" means a benefits plan that pays benefits only for prescription drug expenses or provides only prescription drugs and is delivered or issued for delivery in this State by or through any health carrier in this State.
"Substantiating documentation" means any information specific to the particular health care service or supply provided to a covered person.