New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 28 - UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID BY INSURERS › Section 11:3-28.2 - 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.
"Board" means the Board of the New Jersey Property-Liability Insurance Guaranty Association created in accordance with 17:30A-1 et seq.
"Diagnosis related groups" or "DRG" means a patient classification scheme in which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications. Each DRG exhibits a consistent amount of resource consumption as measured by some unit (for example, length of stay or dollars).
"Excess medical expenses benefits" means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a, 39:6A-4.3, or 39:6A-3.1 that are in excess of $75,000 resulting from personal injury to any one person in any one accident.
"Fund" means the Unsatisfied Claim and Judgment Fund established pursuant to 39:6-61 et seq.
"Health care facility" means a health care provider that is a facility or institution, whether public or private, engaged principally in providing services for diagnosis of treatment of pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, public health center, diagnostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, outpatient clinic, dispensary or residential health care facility.
"Health care provider" or "provider" means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to:
1. A hospital or health care facility which is maintained by a state or any of its political subdivisions;
2. A hospital or health care facility licensed by the Department of Health and Senior Services;
3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital;
5. Hospitals or other health care facilities or treatment centers located in other states or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bio-analytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse-midwives;
16. Certified nurse-practitioners/clinical nurse-specialists;
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
23. Licensed physician assistants;
24. Licensed physical therapists assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
"Health care service" means the preadmission, outpatient, inpatient and postdischarge care provided in or by a health care facility, and such other items or services as are necessary for such care, which are provided by or under the supervision of a physician for the purpose of diagnosis or treatment of pain, injury, disability, deformity or physical condition, including, but not limited to, nursing service, home care nursing and other paramedical service, ambulance service, service provided by an intern, resident in training or physician whose compensation is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and board.
"Insurer" means any person authorized or admitted in this State to write the kinds of insurance specified in paragraphs d and e of 17:17-1, pursuant to 17:17-1 et seq. or 17:32-1 et seq., as applicable. "Insurer" shall not include a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17:22-6.4 0 et seq.
"Licensed nursing personnel" or "licensed nurse" means a nurse licensed by the New Jersey State Board of Nursing or the equivalent from another jurisdiction.
"Medical expense benefits" means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4.
"Medically necessary" is as defined in 11:3-4.2.
"Per diem" means a daily fixed charge which includes room and board and other fees for services and supplies.
"PIP coverage" means personal injury protection coverage as described in 39:6A-4 or 39:6A-3.1.
"Person" means any individual, association, company, corporation, insurer, joint stock company, organization, partnership, society, syndicate, trust, any combination of the foregoing acting in concert or any other entity.
"Pre-screen" means an off-site review of the billings from a health care facility to determine whether the care given and amounts charged are appropriate.
"Provider" means any person that furnishes services or equipment for medical expense benefits for which payment is required to be made under PIP coverage in automobile insurance policies, but does not include health care facilities.
"Reimbursement" refers to reimbursement to insurers by the Fund as provided at 39:6-73.1.
"Uninsured motorist claims" means claims submitted against operators of uninsured vehicles and hit and run claims submitted pursuant to 39:6-61.