New Jersey § 52:17b-197

§ 52:17b-197.

As used in this act: “ Carrier ” means an insurance company, health service corporation, hospital service corporation,

medical service corporation or health maintenance organization which is authorized

to issue health benefits plans in this State and a dental service corporation or dental

plan organization authorized to issue dental plans in this State. “ Covered person ” means a person on whose behalf a carrier which offers a health benefits or dental

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

benefits or dental plan for which the carrier is obligated to pay benefits or provide

services. “ Dental 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. “ Dentist ” means a person who is licensed to practice dentistry by the New Jersey State Board

of Dentistry in accordance with the provisions of Title 45 of the Revised Statutes. “ Health benefits plan ” means a 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: Medicare supplement coverage and risk contracts, accident

only, specified disease or other limited benefit, 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. ), dental or vision care coverage only, or hospital expense or confinement indemnity

coverage only. “ Joint negotiation representative ” means a representative selected by two or more independent physicians or dentists

to engage in joint negotiations with a carrier on their behalf. “ Physician ” means a person who is licensed to practice medicine and surgery by the State Board

of Medical Examiners in accordance with the provisions of Title 45 of the Revised

Statutes. “ Utilization management ” means a system for reviewing the appropriate and efficient allocation of health

care or dental services under a health benefits or dental plan in accordance with

specific guidelines, for the purpose of determining whether, or to what extent, a

health care or dental service that has been provided or is proposed to be provided

to a covered person is to be covered under the health benefits or dental plan.