New Jersey § 2a:53a-32

§ 2a:53a-32.

As used in this act: “ Appropriate and medically necessary ” means the standard for health care services as determined by health care providers

in accordance with generally accepted standards of health care practice. “ Carrier ” means an insurance company, health, hospital or medical service corporation, or

health maintenance organization authorized to issue health benefits plans in this

State or a dental service corporation or dental plan organization authorized to issue

dental benefits plans in this State. “ Covered person ” means a person on whose behalf a carrier or organized delivery system offering a

health or dental benefits plan is obligated to pay benefits or provide services pursuant

to the plan. “ Covered service ” means a health care service provided to a covered person under a health or dental

benefits plan for which the carrier or organized delivery system is obligated to pay

benefits or provide services. “ Dental benefits plan ” means a benefits plan which pays or provides dental expense benefits for covered

services and is delivered or issued for delivery in this State by or through a dental

carrier. “ 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 or dental benefits

plan. Health care provider includes, but is not limited to, a physician, dentist 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. “ Health care service ” means a service or product provided by a health care provider to a covered person

pursuant to a health or dental benefits plan. “ Health care treatment decision ” means a decision made by a health or dental benefits plan at the time health care

services are provided or to be provided, which decision affects the diagnosis, care

or treatment provided to a covered person. “ Organized delivery system ” means an organized delivery system certified or licensed pursuant to P.L.1999, c. 409 ( C.17:48H-1 et seq. ). “ Serious or significant harm ” means death, serious and protracted or permanent impairment of a bodily function

or system, loss of a body organ necessary for normal bodily function, loss of a body

member, or exacerbation of a serious or life-threatening disease or condition that

results in serious or significant harm or requires substantial medical treatment.