N.J. Admin. Code § 11:3-4.2
The following words, phrases, and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Ambulatory surgery facility" or "ambulatory surgical center" (ASC) means:
1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are performed and which is separate and apart from any other facility license. (The ambulatory surgery facility may be physically connected to another licensed facility, such as a hospital, but is corporately, financially and administratively distinct, for example, it uses a separate tax-id number); or
2. A physician-owned single operating room in an office setting that is certified by Medicare.
"Basic automobile insurance policy" or "basic policy" means those private passenger automobile insurance policies issued in accordance with 39:6A-3.1 and N.J.A.C. 11:3-3.
"Clinically supported" means that a health care provider prior to selecting, performing or ordering the administration of a treatment or diagnostic test has:
1. Personally examined the patient to ensure that the proper medical indications exist to justify ordering the treatment or test;
2. Physically examined the patient including making an assessment of any current and/or historical subjective complaints, observations, objective findings, neurologic indications, and physical tests;
3. Considered any and all previously performed tests that relate to the injury and the results and which are relevant to the proposed treatment or test; and
4. Recorded and documented these observations, positive and negative findings and conclusions on the patient's medical records.
"Days" means calendar days unless specifically designated as business days.
1. A calendar and business day both end at the time of the close of business hours. Insurers shall set a close of business time in their Decision Point Review plans;
2. In computing any period of time designated as either calendar or business days, the day from which the designated period of time begins to run shall not be included. The last day of a period of time designated as calendar days is to be included unless it is a Saturday, Sunday, or legal holiday, in which event the period runs until the end of the next day which is neither a Saturday, Sunday, or legal holiday.
3. Example: Decisions on treatment appeals shall be communicated to the provider no later than 10 days from the date the insurer acknowledges receipt to the provider. The insurer acknowledges receipt by facsimile transmission dated 3:00 P.M. on Wednesday, June 8. Day one of the 10-day period is Thursday, June 9. Since the 10th day would be Saturday, June 18, the insurer's decision is due no later than Monday, June 20.
"Decision point" means those junctures in the treatment of identified injuries indicated by hexagonal boxes on the Care Paths where a decision must be made about the continuation or choice of further treatment. The determination whether to administer one of the tests listed in 11:3-4.5(b) is also a decision point for both identified and all other injuries.
"Decision point review" means the procedures in an insurer's approved decision point review plan for the insurer to receive notice and respond to requests for proposed treatment or testing at decision points.
"Diagnostic test" means a medical service or procedure utilizing biomechanical, neurological, neurodiagnostic, radiological, vascular or any means, other than bioanalysis, intended to assist in establishing a medical, dental, physical therapy, chiropractic or psychological diagnosis, for the purpose of recommending or developing a course of treatment for the tested patient to be implemented by the treating practitioner or by the consultant.
"Eligible charge" means the treating health care provider's usual, customary, and reasonable charge or the upper limit of the medical fee schedule as found at N.J.A.C. 11:3- 29 Appendix, whichever is lower.
"Emergency care" means all medically necessary treatment of a traumatic injury or a medical condition manifesting itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. Such emergency care shall include all medically necessary care immediately following an automobile accident, including, but not limited to, immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care. Emergency care extends during the period of initial hospitalization until the patient is discharged from acute care by the attending physician. Emergency care shall be presumed when medical care is initiated at a hospital within 120 hours of the accident.
"Emergency personal injury protection coverage" means the coverage provided by a Special Automobile Insurance Policy pursuant to N.J.S.A. 39:6A-3.3.
"Health care provider" or "provider" means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to:
1. A hospital or health care facility that is maintained by State or any political subdivision;
2. A hospital or health care facility licensed by the Department of Health and Senior Services;
3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiological and diagnostic testing, free-standing emergency clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than a hospital;
5. Hospitals or other health care facilities or treatment centers located in other States or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bioanalytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse mid-wives;
16. Certified nurse practitioners/clinical nurse-specialist;
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
23. Licensed physicians assistants;
24. Licensed physical therapy assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
"Identified injury" means those injuries identified by the Department in the subchapter Appendix as being suitable for medical treatment protocols in accordance with N.J.S.A. 39:6A-3.1a and 39:6A-4a.
"Insurer" means any person or persons, corporation, association, partnership, company, reciprocal exchange or other legal entity authorized or admitted to transact private passenger automobile insurance in this State, or any one member of a group of affiliated companies that transacts business in accordance with a common rating system. Insurer does not include an entity that is self-insured pursuant to 39:6-52. For purposes of communicating with insureds and providers concerning the administration of decision point review plans, "insurer" also means the insurer's PIP vendor.
"Medical expense" means the reasonable and necessary expenses for treatment or services rendered by a provider, including medical, surgical, rehabilitative and diagnostic services and hospital expenses and reasonable and necessary expenses for ambulance services or other transportation, medication and other services, subject to limitations as provided for in the policy forms that are filed and approved by the Commissioner.
"Medically necessary" or "medical necessity" means that the medical treatment or diagnostic test is consistent with the clinically supported symptoms, diagnosis or indications of the injured person, and:
1. The treatment is the most appropriate level of service that is in accordance with the standards of good practice and standard professional treatment protocols including the Care Paths in the Appendix, as applicable;
2. The treatment of the injury is not primarily for the convenience of the injured person or provider; and
3. Does not include unnecessary testing or treatment.
"Network" means an entity other than an insurer that contracts with providers to render health care services or provide supplies at predetermined fees or reimbursement levels.
"Non-medical expense" means charges for those:
1. Products and devices, not exclusively used for medical purposes or as durable medical equipment, such as any vehicles, durable goods, equipment, appurtenances, improvements to real or personal property, fixtures; and
2. Services and activities such as recreational activities, trips and leisure activities.
"Organized delivery system" (ODS) means an organized delivery system certified or licensed pursuant to 17:48H-1 et seq., N.J.A.C. 11:22-4 or N.J.A.C. 11:24B.
"PIP vendor" means a company used by an insurer for utilization management.
"Precertification" or "precertification request" means the procedures in an insurer's approved decision point review plan for the insurer to receive notice and respond to requests for listed specific medical procedures, treatments, diagnostic tests, other services and durable medical equipment that are not subject to decision point review and that may be subject to overutilization.
"Standard automobile insurance policy" or "standard policy" means a private passenger automobile insurance policy issued in accordance with 39:6A-4.
"Standard professional treatment protocols" means evidence-based clinical guidelines/practice/treatment published in peer-reviewed journals.
"Utilization management" means a system for administering some or all of an insurer's decision point review plan, including, but not limited to, receiving and responding to decision point review and precertification requests, making determinations of medical necessity, scheduling and performing independent medical examinations (IMEs), bill review and handling of provider appeals.
N.J. Admin. Code § 11:3-4.2
See: 31 N.J.R. 4210(a), 32 N.J.R. 4005(c).
Inserted "Diagnostic test".
Amended by R.2004 d.218, effective 6/7/2004 (operative October 27, 2004).
See: 35 N.J.R. 3072(a), 36 N.J.R. 2890(a), 36 N.J.R. 4319(a).
Rewrote "Decision point", added "Decision point review", "Emergency personal injury protection coverage", "Insurer", "Network", "PIP vendor" and rewrote "Pre-certification.
Amended by R.2010 d.142, effective 7/6/2010.
See: 41 N.J.R. 2609(a), 42 N.J.R. 1385(a).
Added definitions "Ambulatory surgery facility" and "Organized delivery system".
Administrative correction.
See: 42 N.J.R. 2129(a).
Amended by R.2012 d.187, effective 11/5/2012 (operative January 4, 2013).
See: 43 N.J.R. 1640(a), 44 N.J.R. 383(a), 44 N.J.R. 2652(c).
Added definitions "Days", "Standard professional treatment protocols" and "Utilization management"; and in definition "PIP vendor", substituted "for utilization management" for "to administer its decision point review plan".
Amended by R.2016 d.140, effective 10/17/2016 (operative April 17, 2017).
See: 47 N.J.R. 2658(a), 48 N.J.R. 2144(a).
In the introductory paragraph, inserted a comma following "phrases"; and in definition "Days", in paragraph 2, inserted a comma following "Sunday" twice, and deleted paragraph 3.
Amended by 54 N.J.R. 67(b), effective 1/3/2022