The following glossary of terms is used in conjunction with this manual and in Horizon NJ Health provider contracts.

1.0 Provider

“Affiliate” means any entity, as previously identified or as identified in the future by HMO as an affiliate, which owns or is owned by HMO, directly or indirectly, and any entity, as previously identified or as identified in the future by HMO as an affiliate, which is under common ownership, directly or indirectly, with HMO.

“Capitation” means the prospective payment for primary care services (as defined herein) made at a predetermined, monthly rate reflecting the number of persons in a Primary Care Provider (PCP)’s panel (as defined herein).

“Claim” means a request for payment of charges for services rendered or supplied, provided by a provider to a member.

“Clean claim” means a claim that has no defect or impropriety, including any lack of required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment being made on the claim. A “clean claim” is a claim, or part of a claim, which can be paid exactly as submitted without the need for further documentation or explanation.

“CMS” means the Centers for Medicare & Medicaid Services of the United States government.

“Coinsurance” means a percent of the payment (as defined herein) that a member is responsible to pay for covered services.

“Contested claim” means a claim, or part of a claim, that has not been adjudicated because it has a material defect or impropriety. A “contested claim” is a claim, or part of a claim, which cannot be paid because further documentation or explanation is necessary before the claim can be considered a clean claim.

“Copayment” means a specified dollar amount that a member is responsible to pay for covered services.

“Covered service” means those medically necessary health care services, as set forth in the Medicaid/NJ FamilyCare contract, which shall be no broader or narrower than the services to which members are entitled under the New Jersey Medicaid program unless expressly provided in the Medicaid/NJ FamilyCare contract or set forth in the Provider Manual.

“Declined claim” means a claim that is not covered because the member is not a covered member, the member has not used a Horizon NJ Health network provider, the particular service is not a covered service under the member’s contract or requested information or documentation has not been submitted in a timely manner.

“Emergency services” shall mean health care services required to treat a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance use, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or party. With respect to a pregnant woman who is having contractions, an emergency exists when there is inadequate time to affect a safe transfer to another hospital before delivery; or the transfer may pose a threat to the health or safety of the woman or the unborn child.

“Health benefit plan” means the contract describing the benefits partially or wholly insured, underwritten by the State of New Jersey Department of Human Services, Division of Medical Assistance and Health Services and administered by Horizon NJ Health of which you have received or will receive written notice that this agreement applies.

“Medical emergency” means health care services required to treat a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance use, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists when there is inadequate time to affect a safe transfer to another hospital before delivery; or the transfer may pose a threat to the health or safety of the woman or the unborn child.

“Member” means an enrolled participant in the HMO relating to the managed Medicaid and NJ FamilyCare programs.

“Network hospital” means a hospital that has a contractual arrangement with Horizon NJ Health to provide covered services for certain inpatient and outpatient hospital services.

“Panel” means the group of members who have notified Horizon NJ Health that they have selected you to be their PCP or who may be assigned to you.

“Participating physician” means a physician who has a contractual arrangement with HMO relating to the managed Medicaid and NJ FamilyCare programs.

“Participating provider” means a participating physician, network hospital or other health care professional or entity who has a contractual arrangement with HMO relating to the managed Medicaid and NJ FamilyCare programs.

“Payment” means the amount payable to you for covered services, which shall be either of the following types: (i) provider’s billed charges or Horizon NJ Health’s applicable fee, whichever is less; or (ii) capitation. You acknowledge that the type of payment generally and the type of payment for any particular covered service is determined by Horizon NJ Health and is subject to revision from time to time.

“Primary Care Provider” means any duly licensed medical doctor (MD) or doctor of osteopathy (DO) who has entered into a physician agreement with the HMO relating to the managed Medicaid and NJ FamilyCare programs, and who is responsible for providing all required primary care services to enrollees, including periodic examinations, preventive health care and counseling, immunizations, diagnoses and treatment of illness or injury, coordination of overall medical care, record maintenance and for maintaining continuity of patient care.

“Primary care services” means the following medically necessary basic health care services:

• All primary ambulatory care visits and routine office procedures; periodic physical examinations
• Appropriate referrals to specialty physicians and other health care providers, who have an agreement with HMO relating to the managed Medicaid and NJ FamilyCare programs to provide services to members. In the case of a medical emergency, no prior authorization or approval is required for referral to a non-affiliated provider. Horizon NJ Health shall periodically supply to the physician a list of primary care and specialty physicians affiliated with the managed Medicaid and NJ FamilyCare programs
• Provision or arrangement for primary care services 24 hours a day, seven days per week
• Obtaining of lab specimens for lab studies, including Pap tests and phlebotomy services
• Supervision, coordination and management of the member’s care

“Specialty physician” means a duly licensed medical doctor (MD) or doctor of osteopathy (DO), other than a PCP, who has entered into a physician agreement with the HMO relating to the managed Medicaid and NJ FamilyCare programs, and who is responsible for providing health care services that are ordered and approved by the PCP or Horizon NJ Health.

“Specialty physician services” means those medically necessary covered services provided by participating physicians, which are not primary care services.

“You,” “provider,” “provider/subcontractor” means the provider bound by this agreement.