Chapter 2 - PAID CLAIMS DEFINITION
Current through 2021-51, December 22, 2021
PRINCIPAL REASON OR PURPOSE FOR PROPOSING THIS RULE:
PL 2005, Chapter 400, Part B, section B-2, 1 states:
RECOMMENDED DEFINITION OF PAID CLAIMS
For the purpose of calculating savings offset payment assessments for health insurance carriers, third-party administrators and employee benefit excess insurance carriers, the term "paid claims" shall be defined as:
All payments made by health insurance carriers, third-party administrators and employee benefit excess carriers for health and medical services provided under policies issued pursuant to the laws of this State that insure residents of this State or, in the case of third-party administrators, for health care for residents of this State except that paid claims shall not include:
For the purposes of this definition of "paid claims" claims related expenses shall include:
In those instances in which a health insurance carrier, employee benefit excess insurance carrier, or third party administrator is contractually entitled to withhold certain amounts from payments due to providers of health and medical services in order to help assure that the providers can fulfill any financial obligations they may have under a managed care risk arrangement, the full amounts due the providers before application of such withholds shall be reflected in the calculation of "paid claims."
For the purposes of this definition of "paid claims" the phrase "health and medical services" shall include but not be limited to any services included in the furnishing of medical care, dental care to the extent covered under a medical insurance policy, pharmaceutical benefits, hospitalization including but not limited to services provided in a hospital or other medical facilities; ancillary services, including but not limited to ambulatory services; physician and other practitioner services including but not limited to services provided by a physician's assistant, nurse practitioner or midwife; and behavioral health services including but not limited to mental health and substance abuse services.
January 23, 2006 - filing 2006-19
P.L. 2005 ch. 400
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