17B:30-60 Definitions relative to certain dental provider networks.
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/nj/title-17b/chapter-30/17b-30-60·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
1. As used in this act:
"Contracting entity" means any person or entity that enters into direct contracts with providers for the delivery of dental services in the ordinary course of business, including a third party administrator as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1) and a dental carrier.
"Covered person" means an individual who is covered under a dental benefits or health benefits plan for dental services.
"Dental benefits plan" means a benefits plan which pays or provides dental expense benefits for covered dental services and is delivered or issued for delivery in this State by or through a dental carrier on a stand-alone basis.
"Dental carrier" means a dental insurance company, dental service corporation, or dental plan organization authorized to provide a dental benefits plan in New Jersey or a health benefits plan in New Jersey that includes coverage for dental services.
"Dental services" means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease. Dental services shall not include those services delivered by a provider under a health benefits plan that are billed as medical services under that plan.
"Health benefits plan" means any hospital and medical expense incurred policy, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical, dental, or health care services, whether by insurance or otherwise. Health benefits plan shall include a dental benefits plan. "Health benefits plan" shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and private passenger automobile insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; coverage similar to the foregoing as specified in federal regulations issued pursuant to the federal "Health Insurance Portability and Accountability Act of 1996," P.L.104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; benefits for long-term care, nursing home care, home health care, or community-based care; specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or such other similar, limited benefits as are specified in regulations;
Medicare supplemental health insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C. s.1395ss(g)(1)); coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code (10 U.S.C. s.1071 et seq.); or other similar limited benefit supplemental coverages.
"Provider" means an individual or entity which, acting within the scope of its licensure or certification, provides dental services or supplies defined by the health benefits or dental benefits plan. Provider includes, but is not limited to, a dentist, physician or other health care professionals licensed pursuant to Title 45 of the Revised Statutes acting within the scope of his or her licensure. "Provider" shall not include a physician organization or physician hospital organization that leases or rents the physician organization's or physician hospital organization's network to a third party.
"Provider network contract" means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and providing for the delivery of and payment for dental services to covered persons.
"Third party" means a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the dental services or contractual discounts of a provider network contract. "Third party" shall not include any employer or other group for whom the contracting entity or dental carrier provides administrative services, including at least the payment of claims.
L.2019, c.254, s.1.