N.J. Admin. Code § 11:4-57.2 - Definitions

Current through Register Vol. 54, No. 7, April 4, 2022

The following words and terms, as used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:

"Benefit limit" means any restriction, condition, or limitation (including, but not limited to, visit limits, dollar limits and preauthorization requirements) applied to the provision of health care services or benefits in a health insurance policy or health maintenance organization contract.

"Biologically-based mental illness" (BBMI) means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism.

"Carrier" means any insurer authorized to sell health insurance pursuant to Title 17B of the New Jersey Statutes; a health, hospital or medical service corporation; or a health maintenance organization.

"Commissioner" means the Commissioner of the Department of Banking and Insurance.

"Exclusion" means a provision in a policy or contract that limits the scope of coverage by specifying causes and conditions for which benefits are not provided.

"Form" means any individual or group health insurance policy, health maintenance organization contract, any rider or endorsement for use with such policy or contract, certificates and evidence of coverage forms.

"Preauthorization" means a carrier's authorization, using paper or electronic means, for specified services or supplies that is given prior to the date the services or supplies are provided.

Notes

N.J. Admin. Code § 11:4-57.2

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