17B:27B-1 Definitions relative to third party administrators, billing services.
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/nj/title-17b/chapter-27b/17b-27b-1·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
1. As used in this act:
"Benefits payer" means an insurer authorized to issue health or dental benefits plans in this State, or any other person who undertakes to provide and assumes financial risk for the payment of health or dental benefits and is obligated to pay claims for health or dental benefits to providers or other claimants.
"Client" means a health care provider that contracts with a third party billing service to remit claims to benefits payers on behalf of the provider or other claimant.
"Commissioner" means the Commissioner of Banking and Insurance.
"Enrollee" means a person entitled to receive benefits under a health benefits plan.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense or dental benefits for covered services.
"Health care provider" or "provider" means an individual or entity which provides a covered benefit or service.
"Insurer" means a licensed health insurer, health, hospital or medical service corporation, health maintenance organization, dental service corporation or dental plan organization.
"Third party administrator" means a person or entity that: processes claims and pays claims on behalf of a benefits payer without the assumption of financial risk for the payment of health or dental benefits. Third party administrator shall include:
(1)an entity not licensed as an insurer that is not an affiliate or subsidiary of an insurer, that processes claims on behalf of a benefits payer;
(2)an entity that is a subsidiary or affiliate of an insurer that processes claims on behalf of the insurer; and
(3)an entity that is a subsidiary or affiliate of an insurer that only processes claims on behalf of benefits payers other than insurers. Third party administrator shall not include an employee, affiliate or subsidiary of a benefits payer formed for the purpose of processing and paying claims solely on behalf of the benefits payer, nor shall it include a collection agency or bureau or pharmacy benefits manager.
"Third party billing service" means a person or entity that is paid by a health care provider to process claims or claims payments on behalf of the health care provider.
L.2001,c.267,s.1.