New Jersey § 26:2ss-3

§ 26:2ss-3.

As used in this act: “ Carrier ” means an entity that contracts or offers to contract to provide, deliver, arrange

for, pay for, or reimburse any of the costs of health care services under a health

benefits plan, including: an insurance company authorized to issue health benefits

plans; a health maintenance organization; a health, hospital, or medical service

corporation; a multiple employer welfare arrangement; the State Health Benefits

Program and the School Employees' Health Benefits Program; or any other entity providing

a health benefits plan. Except as provided under the provisions of this act, “carrier” shall not include

any other entity providing or administering a self-funded health benefits plan. “ Commissioner ” means the Commissioner of Banking and Insurance. “ Covered person ” means a person on whose behalf a carrier is obligated to pay health care expense

benefits or provide health care services. “ Department ” means the Department of Banking and Insurance. “ Emergency or urgent basis ” means all emergency and urgent care services including, but not limited to, the

services required pursuant to N.J.A.C.11:24-5.3 . “ 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. For the purposes of this act, “health benefits plan” shall not include the following

plans, policies or contracts: Medicaid, Medicare, Medicare Advantage, accident only,

credit, disability, long-term care, TRICARE 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. ), a dental plan as defined pursuant to section 1 of P.L.2014, c. 70 ( C.26:2S-26 ) and hospital confinement indemnity coverage. “ Health care facility ” means a general acute care hospital, satellite emergency department, hospital based

off-site ambulatory care facility in which ambulatory surgical cases are performed,

or ambulatory surgery facility, licensed pursuant to P.L.1971, c. 136 ( C.26:2H-1 et seq. ). “ Health care professional ” means an individual, acting within the scope of his licensure or certification,

who provides a covered service defined by the health benefits plan. “ Health care provider ” or “ provider ” means a health care professional or health care facility. “ Inadvertent out-of-network services ” means health care services that are: covered under a managed care health benefits

plan that provides a network; and provided by an out-of-network health care provider

in the event that a covered person utilizes an in-network health care facility for

covered health care services and, for any reason, in-network health care services

are unavailable in that facility. “ Inadvertent out-of-network services ” shall include laboratory testing ordered by an in-network health care provider and

performed by an out-of-network bio-analytical laboratory. “ Knowingly, voluntarily, and specifically selected an out-of-network provider ” means that a covered person chose the services of a specific provider, with full

knowledge that the provider is out-of-network with respect to the covered person's

health benefits plan, under circumstances that indicate that covered person had the

opportunity to be serviced by an in-network provider, but instead selected the out-of-network

provider. Disclosure by a provider of network status shall not render a covered person's decision

to proceed with treatment from that provider a choice made “knowingly” pursuant to

this definition. “ Medicaid ” means the State Medicaid program established pursuant to P.L.1968, c. 413 ( C.30:4D-1 et seq. ). “ Medical necessity ” or “ medically necessary ” means or describes a health care service that a health care provider, exercising

his or her prudent clinical judgment, would provide to a covered person for the purpose

of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms

and that is: in accordance with the generally accepted standards of medical practice;

clinically appropriate, in terms of type, frequency, extent, site, and duration, and

considered effective for the covered person's illness, injury, or disease; not primarily

for the convenience of the covered person or the health care provider; and not more

costly than an alternative service or sequence of services at least as likely to produce

equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that

covered person's illness, injury, or disease. “ Medicare ” means the federal Medicare program established pursuant to Pub.L.89-97 ( 42 U.S.C. s.1395 et seq. ). “ Self-funded health benefits plan ” or “ self-funded plan ” means a self-insured health benefits plan governed by the provisions of the federal

“Employee Retirement Income Security Act of 1974,” 29 U.S.C. s.1001 et seq.