New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
"Adverse change" or "adverse amendment" means any action taken by a carrier that that could reasonably be expected to have a material adverse impact on either the aggregate level of payment to a health care provider or the administrative expenses incurred by the provider in complying with the change. Examples include, but are not limited to, a carrier's discontinuance of reimbursement for a particular service (CPT or HCPCS code); a carrier's refusal to pay, or payment of decreased reimbursement, based on the location of service or professional designation of the individual providing the service; or the imposition of a prior certification requirement for a category of services performed within that provider's practice. An adverse change shall not include:
1. Fee schedule changes attributable to a third party and over which the carrier has no control (for example, the Medicare fee schedule);
2. Changes made as a result of changes in provider billing practices, such as an increase in a facility's Charge Master; and
3. Changes resulting from the introduction of, discontinuance of, or changed usage of a CPT code, HCPCS code, or modifier by the American Medical Association or the Centers for Medicare & Medicaid Services.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, and health maintenance organization authorized to issue health benefits plans in this State. "Carrier" also includes organized delivery systems as defined in 11:22-4.2 and 11:24B-1.2.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"CPT code" means the American Medical Association's current procedural terminology code.
"Department" means the Department of Banking and Insurance.
"Edit" means a practice or procedure pursuant to which one or more adjustments are made by the carrier to CPT codes or HCPCS codes included in a claim that result in:
1. Payment being made based on some, but not all, of the CPT codes or HCPCS codes included in the claim;
2. Payment being made based on different CPT codes or HCPCS codes than those included in the claim;
3. Payment for one or more of the CPT codes or HCPCS codes included in the claim being reduced by application of Multiple Procedure Logic;
4. Payment for one or more of the CPT codes or HCPCS codes being denied; or
5. Any combination of 1 through 4 above.
"Fee schedule" means the complete fee schedule that is applicable to and will be a part of an existing or contemplated provider agreement with a contracting provider.
"HCPCS code" means the Centers for Medicare & Medicaid Services Healthcare Common Procedure Coding System code.
"Health benefits plan" means a hospital and medical expense insurance policy; health service corporation contract; hospital service corporation contract; medical service corporation contract; health maintenance organization subscriber contract; or other plan for medical care delivered or issued for delivery in this State. For purposes of this subchapter, health benefits plan shall not include one or more, or any combination, of the following: coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; stop loss or excess risk insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health benefits plans shall not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and such other similar, limited benefits as are specified in Federal regulations. Health benefits plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health benefits plan maintained by the same plan sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. Health benefits plan shall not include the following if it is offered as a separate policy, certificate or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the Federal Social Security Act ( 42 U.S.C. §
										1395ss(g)(1) ); and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code ( 10 U.S.C. §§
										1071 et seq.); and similar supplemental coverage provided under a group health plan.
"Health care provider" or "provider" means an individual or entity that, acting within the scope of its license or certification, provides a covered service or supply as defined by the health benefits plan. Health care provider includes, but is not limited to, a physician or other health care professional licensed pursuant to Title 45 of the Revised Statutes, and a hospital or other health care facility licensed pursuant to Title 26 of the Revised Statutes.
"Most favored nation clause" means any clause in a provider agreement that requires the provider to maintain or reduce the rate specified in the agreement based upon a lower rate the provider has accepted or has agreed to accept from a third party(ies) for providing the same or a comparable service or supply.
"Multiple Procedure Logic" means the practices or procedures used by a carrier to reduce the allowable amount for one or more of the CPT codes or HCPCS codes included in a claim as a result of multiple surgical procedures or multiple services having been performed on the same patient on the same date of service.
"Participating provider" means a provider who is a party to a provider agreement with a carrier.
"Practice limitation" means any restriction a provider imposes on his or her practice that affects the access of covered persons to his or her services including, but not limited to, treating only persons who are confined to a hospital or other institution, treating only persons of certain ages, refusing new patients at certain office locations, and refusing to perform certain procedures (for example, obstetrician/gynecologists who will not perform deliveries).
"Provider agreement" or "agreement" means a contract between a carrier and a provider, or between a carrier and another entity pursuant to which the provider is covered, and under the terms of which the carrier agrees to pay the provider for, and the provider agrees to provide covered health care services or supplies to persons covered by a health benefits plan issued by the carrier. "Provider agreement" or "agreement" includes the agreement, any fee schedule that is part of the agreement, and any appendices, attachments or amendments to the agreement.