New Jersey § 26:2s-2

§ 26:2s-2.

As used in sections 2 through 19 of this act: 1 “ Behavioral health care services ” means procedures or services rendered by a health care provider for the treatment

of mental illness, emotional disorders, or drug or alcohol abuse. “Behavioral health care services” does not include: any quality assurance or utilization

management activities or treatment plan reviews conducted by a carrier, or a private

entity on behalf of the carrier, pertaining to these services, whether administrative

or clinical in nature; or any other administrative functions, including, but not

limited to, accounting and financial reporting, billing and collection, data processing,

debt or debt service, legal services, promotion and marketing, or provider credentialing. “ Carrier ” means an insurance company, health service corporation, hospital service corporation,

medical service corporation , or health maintenance organization authorized to issue health benefits plans in this

State. “ Commissioner ” means the Commissioner of Banking and Insurance . “ Contract holder ” means an employer or organization that purchases a contract for services. “ Covered person ” means a person on whose behalf a carrier offering the plan is obligated to pay benefits

or provide services pursuant to the health benefits plan. “ Covered service ” means a health care service provided to a covered person under a health benefits

plan for which the carrier is obligated to pay benefits or provide services. “ Department ” means the Department of Banking and Insurance . “ Health benefits plan ” means a benefits plan which pays or provides hospital and medical expense benefits

for covered services, and is delivered or issued for delivery in this State by or

through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage

and risk contracts to the extent not otherwise prohibited by federal law. For the purposes of this act, health benefits plan shall not include the following

plans, policies , or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement

coverage, coverage arising out of a workers' compensation or similar law, automobile

medical payment insurance, personal injury protection insurance issued pursuant to

P.L.1972, c. 70 ( C.39:6A-1 et seq. ) , or hospital confinement indemnity coverage. “ Health care provider ” means an individual or entity which, acting within the scope of its licensure or

certification, provides a covered service defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health

care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital

and other health care facilities licensed pursuant to Title 26 of the Revised Statutes. “ Independent utilization review organization ” means an independent entity comprised of physicians and other health care professionals

who are representative of the active practitioners in the area in which the organization

will operate and which is under contract with the department to provide medical necessity

or appropriateness of services appeal reviews pursuant to this act. “ Managed behavioral health care organization ” means an entity, other than a carrier, which contracts with a carrier to provide,

undertake to arrange, or administer behavioral health care services to covered persons

through health care providers employed by the managed behavioral health care organization

or otherwise make behavioral health care services available to covered persons through

contracts with health care providers. “Managed behavioral health care organization” does not include a person or entity

that, for an administrative fee only, solely arranges a panel of health care providers

for a carrier for the provision of behavioral health care services on a discounted

fee-for-service basis. “ Managed care plan ” means a health benefits plan that integrates the financing and delivery of appropriate

health care services to covered persons by arrangements 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. “ Subscriber ” means, in the case of a group contract, a person whose employment or other status,

except family status, is the basis for eligibility for enrollment by the carrier or,

in the case of an individual contract, the person in whose name the contract is issued. “ 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. 1

N.J.S.A. §§ 26:2S-2 to 26:2S-18.