New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24A - HEALTH CARE QUALITY ACT APPLICATION TO INSURANCE COMPANIES, HEALTH SERVICE CORPORATIONS, HOSPITAL SERVICE CORPORATIONS, AND MEDICAL SERVICE CORPORATIONS
Subchapter 1 - GENERAL PROVISIONS
Section 11:24A-1.2 - Definitions

Current through Register Vol. 56, No. 6, March 18, 2024

For the purposes of this chapter, the words and terms set forth below shall have the following meanings, unless the word or term is further defined within a subchapter of this chapter, or the context clearly indicates otherwise:

"Act" means the Health Care Quality Act, P.L. 1997, c. 192 (as codified: 26:2S-1 et seq.; 26:2J-4.1 6, 18.1 and 24; 17:48-6r, 17:48A-7p, 17:48E-35.1 5, 17B:26-2.1n, 17B:27-46.1q, 17B:27A-2.3 and 17B:27A-19.5; and 34:13A-31 ).

"Adverse benefit determination" means a denial, reduction or termination of, or a failure to make payment (in whole or in part) for, a benefit, including a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from application of any utilization review, denial of a request for an in-plan exception, as well as a failure to cover an item or service for which benefits are otherwise provided because the carrier determines the item or service to be experimental or investigational, cosmetic, dental rather than medical, excluded as a pre-existing condition or because the carrier has rescinded the coverage.

"Carrier" means a insurance company authorized to transact the business of insurance in this State and doing a health insurance business in accordance with 17B:17-1 et seq., a hospital service corporation authorized to do business pursuant to 17:48-1 et seq., a medical service corporation authorized to do business pursuant to 17:48A-1 et seq. or a health service corporation authorized to do business pursuant to 17:48E-1 et seq.

"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 covered under a health benefits plan issued by a carrier.

"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.

"Continuous quality improvement" or "CQI" means an on-going and systematic effort to measure, evaluate, and improve either a carrier's process of providing quality health care services to covered persons with respect to managed care plans, or the carrier's process of performing utilization management functions with respect to health benefits plans in which utilization management has been incorporated.

"Contract holder" means an employer or organization that purchases a contract or policy for the provision of health care services covered under the terms of the policy or contract or for the payment of benefits therefor.

"Covered person" means the person on whose behalf a carrier is obligated to pay benefits or provide health care services pursuant to the health benefits plan.

"Department" means the New Jersey Department of Banking and Insurance.

"Emergency" means a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in: placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists where: there is inadequate time to effect a safe transfer to another hospital before delivery; or the transfer may pose a threat to the health or safety of the woman or the unborn child.

"Final internal adverse benefit determination" means an adverse benefit determination that has been upheld by a carrier at the completion of the internal appeal process, an adverse benefit determination with respect to which the carrier has waived its right to an internal review of the appeal, an adverse benefit determination for which the carrier did not comply with the requirements of 11:24A-3.4 or 3.5 and an adverse benefit determination for which the covered person or provider has applied for expedited external review at the same time as applying for an expedited internal appeal.

"Financial incentive arrangement" means a formal mechanism instituted by a carrier or a secondary contractor that exposes a provider, or group of providers, to risk or reward based upon meeting or failing to meet prescribed standards.

"Financial risk" means participation in financial gains or losses accruing pursuant to a contractual arrangement, based on aggregate measures of medical expenditures or utilization.

"Gatekeeper system" means a system in which a covered person's level of benefits for all or a specified set of health care services under a policy or contract is dependent upon the covered person obtaining appropriate referrals for the services through a primary care provider or the carrier.

"Health benefits plan" means a policy or contract for the payment of benefits for hospital and medical expenses or the provision of hospital and medical services delivered or issued for delivery in this state by a carrier.

The term "health benefits plan" specifically includes:

The term "health benefits plan" specifically excludes:

"IHC Program" means the Individual Health Coverage Program set forth at 17B:27A-2 et seq., and any rules promulgated pursuant thereto.

"Independent Health Care Appeals Program" means the external appeals process for a covered person or provider on behalf of the covered person with the covered person's consent, to appeal a decision of a carrier to deny, reduce or terminate services or payment of benefits resulting from a decision by a carrier with respect to the covered person which services are otherwise covered under the health benefits plan.

"Independent utilization review organization" or "IURO" means an independent organization with which the Department contracts to provide independent reviews through the Independent Health Care Appeals Program of carrier determinations regarding medical necessity or appropriateness of services which are contested by the covered person or a provider on behalf of the covered person.

"In-plan exception" means a request by a covered person or provider to obtain medically necessary covered services from an out-of-network provider, with the covered person's liability limited to network level cost sharing, because the carrier's network does not have providers who are qualified, accessible, and available to perform the medically necessary covered service the covered person requires.

"Managed care plan" means a health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangement with participating providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating providers and procedures provided for in the plan.

"Participating provider" means a provider which, under contract or other arrangement acceptable to the Department with the carrier, its contractor or subcontractor, has agreed to provide health care services or supplies to covered persons in the carrier's managed care plan(s) for a predetermined fee or set of fees.

"Post-service claim" means any claim for a benefit that is not a "pre-service claim."

"Pre-service claim" means any claim for a benefit with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

"Primary care provider" or "PCP" means an individual participating provider who supervises, coordinates and provides initial and basic care to members and maintains continuity of care for the members.

"Primary contractor" means a provider that agrees directly with a carrier to provide one or more services or supplies directly to a carrier's covered persons.

"Provider" means any physician or other health care professional, hospital, facility or other person who is licensed or otherwise authorized to provide health care services or other services in the state or jurisdiction in which the services are furnished.

"Religious employer" means an organization that is organized and operates as a nonprofit entity and is referred to at section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986 (26 U.S.C. § 6033).

"Secondary contractor" means a person who agrees to arrange for the provision of one or more services or supplies for a carrier's covered persons. A primary contractor also may be a secondary contractor when acting as a broker or administrator for the rendering of services or supplies that, in scope of licensure, type or quantity, the primary contractor (provider) alone could not offer directly to the carrier's covered persons.

"SEH Program" means the Small Employer Health Benefits Program set forth at 17B:27A-17 et seq., and any rules promulgated pursuant thereto.

"Subscriber" means, in the case of a group policy or contract, an individual whose employment or other status, except family status, is the basis for eligibility for coverage under the policy or contract or, in the case of an individual policy or contract, the person in whose name the contract is issued.

"Urgent care claim" means any claim for medical care or treatment with respect to which application of the time periods for making non-urgent determinations, in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or which, in the opinion of a physician with knowledge of the claimant's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

"Utilization management" means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the health benefits plan. The system may include: preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory care procedures and retrospective review.