SENATE, No. 2249
STATE OF NEW JERSEY
INTRODUCED NOVEMBER 17, 1997
By Senators CARDINALE, SINAGRA and Kosco
An Act concerning prior approval of covered health care services of health benefits plans.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in this act:
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.
"Covered person" means a person on whose behalf a carrier offering the health benefits plan is obligated to pay benefits or provide health care services pursuant to the health benefits plan.
"Covered health care service" means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services.
"Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. For the purposes of this act, health benefits plan shall not include the following plans, policies or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement coverage, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.
"Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes.
"Prior approval" means the process by which a carrier determines the medical necessity or medical appropriateness, or both, of otherwise covered health care services prior to rendering of those health care services.
2. No carrier shall deny coverage for covered health care services provided to a covered person when prior approval has been obtained from the carrier for those health care services, unless the approval was based upon fraudulent information submitted by the covered person or the health care provider or the health care services were not rendered within the time limit, if any, specified in the prior approval.
3. This act shall take effect on the 30th day following enactment.
STATEMENT
This bill prohibits insurers from denying payment of covered health care services for which prior approval was provided, except when the approval was based upon fraudulent information submitted by the covered person or his health care provider or when the health care services were not rendered within the time limit specified in the prior approval.
Requires health insurance carriers to pay for covered health care services for which prior approval was given.