New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.2 - 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:
"Affiliate" or "affiliated" means a person that directly, or indirectly through one or more intermediaries, controls, is controlled by or is under common control with another person.
"Approved workers' compensation managed care organization" means a workers' compensation managed care organization which has been approved by the Department.
"Care coordinator physician" means a licensed physician employed by or under contract with, directly or indirectly, the workers' compensation managed care organization, and who is responsible for providing primary medical care to the injured worker, maintaining the continuity of the injured worker's medical care and initiating all referrals to other providers.
"Case manager" means an employee of the workers' compensation managed care organization who is either a licensed registered nurse or a licensed physician, designated to assume responsibility for coordination of services and continuity of care.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Compensation Rating and Inspection Bureau" or "CRIB" means the Bureau created, organized and supervised by the Commissioner of the New Jersey Department of Banking and Insurance in accordance with 34:15-1 et seq., the New Jersey Workers' Compensation Law.
"Department" means the Department of Banking and Insurance.
"Employee" or "worker" means an individual covered under a policy of workers' compensation insurance issued pursuant to 34:15-1 et seq., the New Jersey Workers' Compensation Law.
"Employer" means an employer obligated under 34:15-1 et seq., the New Jersey Workers' Compensation Law, to provide to its employees workers' compensation insurance coverage.
"Insured" means any employer obligated under the New Jersey Workers' Compensation Law to be insured under a policy of workers' compensation insurance issued by an insurer authorized to write workers' compensation insurance in the State of New Jersey.
"Insurer" means any insurer authorized to write workers' compensation insurance in the State of New Jersey.
"Medical director" means a licensed physician, board certified in occupational medicine, internal medicine, orthopedics, neurosurgery, neurology or related fields, having a minimum of three years experience in treating either trauma or work-related injuries or illness, who is employed by the WCMCO for the primary purpose of providing full-time, day-to-day direction, management and supervision of medical care.
"Medical service" means any medical, surgical, chiropractic, dental, hospital, nursing, ambulance, or related services or any medication, crutch, prosthesis, brace, support or physical restorative device.
"Medical service provider" or "provider" means any physician, hospital or other person or entity licensed or otherwise authorized by any state to furnish medical services.
"Participating physician" or "participating provider" means a health care physician or provider who is under contract, directly or indirectly, with a workers' compensation managed care organization.
"Person" means any natural person, corporation, association, partnership or other legal entity.
"Physician" means a person duly licensed by the State of New Jersey or by any other state to practice one or more of the healing arts in that state within the limits of the license of the licentiate.
"Report" means medical information transmitted in written form containing relevant subjective and objective findings. Reports may take the form of brief or complete narrative reports, a treatment plan, a closing examination report, or any forms as prescribed by the Department.
"Workers' compensation managed care organization" or "WCMCO" means any entity that manages the utilization of care and costs associated with claims covered by workers' compensation insurance, which may be approved by the Department in accordance with this subchapter.