New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 22 - HEALTH BENEFIT PLANS › Subchapter 3 - ELECTRONIC RECEIPT AND TRANSMISSION OF HEALTH CARE CLAIMS › Section 11:22-3.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words, phrases and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Agent" means any entity, including a subsidiary of a carrier, or an organized delivery system as defined by 17:48H-1 with which a carrier has contracted to perform claims processing or claims payment services.
"Claim" or "insured claim" means a request by a covered person, a participating health care provider, or a nonparticipating health care provider who has received an assignment of benefits from the covered person, for payment relating to health care services or supplies or dental services or supplies covered under a health benefits plan or dental plan issued by a carrier.
"Clearinghouse" or "healthcare clearinghouse" means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches, that does either of the following functions:
1. Converts or facilitates the conversion of health information, that is received from another entity in a nonstandard Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, (HIPAA) format or containing nonstandard data content, into standard HIPAA data elements or a standard HIPAA transaction; or
2. Receives a standard HIPAA transaction from another entity and converts or facilitates the conversion of health information into nonstandard format or nonstandard data content for the receiving entity.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Covered person" means a person on whose behalf a payer has an obligation to pay benefits for health care services pursuant to a plan, policy, contract, certificate, or any other document.
"Covered service or supply" means a health care service or supply provided to a covered person under a health benefits or dental plan for which the payer is obligated to pay benefits or provide services or supplies subject to any applicable deductible, coinsurance or co-payment.
"Health benefit payer" or "payer" means those entities identified in 11:22-3.1(d)  that are subject to the provisions of this chapter.
"Health care provider" or "provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service or supply defined by the health benefits or dental plan. Health care provider includes, but is not limited to, a physician, dentist or other health care professional licensed pursuant to Title 45 of the Revised Statutes; a hospital and other health care facility licensed pursuant to Title 26 of the Revised Statutes; and/or a purveyor of prescription, pharmaceutical products or durable medical goods or equipment.
"Health care transaction" or "transaction," for purposes of this subchapter only, means the exchange of information between two or more parties to carry out the financial and administrative activities related to coverage under a health benefits or dental plan, including, but not limited to, health claims and equivalent encounter information, health care payment and admittance advice, health claims status, enrollment and disenrollment in a health plan, eligibility for a health plan, health or dental plan premium payments, first report of injury, deferral certification and authorization and health care attachments.
"Health insurance coverage" means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care, under any hospital or medical expense policy or certificate or health maintenance organization contract offered by a health benefit payer. The following shall constitute excepted benefits:
1. 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; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverages, as specified by Federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;
2. Benefits provided under a separate policy, certificate or contract of insurance, or otherwise not an integral part of the group health plan 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 by Federal regulation;
3. Benefits offered as independent, noncoordinated benefits, hospital indemnity or other fixed indemnity insurance; and
4. Benefits offered as a separate insurance policy, certificate or contract of insurance, Medicare supplement 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 in addition to coverage under a group health plan.
"Small Employer Health Benefits Plan" means, for purposes of this subchapter only, any plan identified as such by 17B:27A-17 or a "small health plan" pursuant to 45 CFR §
										160.103.
"Standard" means a prescribed set of rules, conditions, transaction sets or requirements concerning classification of components, specification of materials, performance or operations, or delineation of procedures, in describing products, systems, services or practices.
"System" or "system for the electronic receipt and transmission of health care claim information" means that electronic network established in accordance with 42 U.S.C. §§
										1320d et seq. for the transaction of health care related information including:
1. Health claims or equivalent encounter information, including institutional, professional, pharmacy and dental health claims;
2. Enrollment and disenrollment in a health plan;
3. Eligibility for a health plan;
4. Health care payment and remittance advice;
5. Health care premium payments;
6. First report of injury;
7. Health claim status; and
8. Referral certification and authorization.