Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-29 - RULES AND REGULATIONS FOR HEALTH MAINTENANCE ORGANIZATIONS
Rule 111-8-29-.02 - Definitions

(a) "Basic Health Care Services" means healthcare services which an enrolled population might reasonably require in order to be maintained in good health, including as a minimum but not restricted to, preventive care, emergency care, inpatient hospital and physician care, and outpatient medical services;

(b) "Commissioner" means the Commissioner of the Georgia Department of Community Health or his designee;

(c) "Complaint" means a written expression of concern by an enrollee or provider regarding the provision of health care services by the HMO or a condition in the operation of an HMO which affects an enrollee or provider to such an extent as to be viewed by such as deserving of formal redress;

(d) "Department" means the Georgia Department of Community Health (DCH);

(e) "Enrollee" means an individual person who is enrolled in a health benefits plan;

(f) "Governing Body" means the person or persons, natural or corporate, in which the ultimate responsibility, authority and accountability for the conduct of the HMO is vested;

(g) "Health Benefits Plan" means any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services and at least part of such arrangement consists of arranging for or the provision of health care services, as distinguished from an arrangement which provides only for indemnification against the cost of such services, on a prepaid basis through insurance or otherwise;

(h) "Health Care Services" means any services included in the furnishing to any individual of medical or dental care, or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury;

(i) "Health Education" means the provision of health information and the use of educational techniques to modify an individual's or family's knowledge and/or behavior to achieve and maintain optimum physical and mental health and to prevent illness, injury, chronicity, or unnecessary disability;

(j) "Health Maintenance Organization" or "HMO" means any legal entity subject to the provisions of the Georgia Health Maintenance Organization Act;

(k) "Health Professional" means those professionals engaged in the delivery of health services who are currently licensed to practice in the State of Georgia, or provide services authorized under an institutional license, or are certified, or practice under authority consistent with Georgia laws;

(l) "In-Area" means the geographical area defined by the health maintenance organization as its service area in which it provides health services to its enrollees directly through its own resources or through arrangements with other providers in the area;

(m) "Insurance Commissioner" means the Insurance Commissioner of the State of Georgia or his designee;

(n) "Medical Audit" means the retrospective examination and evaluation of the documentation of clinical application of medical knowledge as revealed inpatient health records for the purposes of education, accountability, and quality assurance;

(o) "Out-of-Area" means that area outside of the geographical area defined by the health maintenance organization as its service area;

(p) "Physician" means an individual who is currently licensed to practice medicine, surgery, or osteopathy in the State of Georgia, under the Georgia Medical Practice Act, Chapter 84-9, Georgia Laws Ann.;

(q) "Primary Care Physician" means the physician responsible for the management of medical care and coordination of health care services of an enrollee;

(r) "Provider" means any physician, hospital, or other person or facility which is licensed or otherwise authorized in this State to furnish health care services;

(s) "Peer Review" means professional evaluation by currently licensed professional persons in the same category as those being reviewed, of the performance of individuals in the medical and related health care fields for the purpose of achieving and maintaining high standards of care and professional practice;

(t) "Person" means any individual, institution, partnership, association, corporation, the State, or any municipalities or subdivision thereof, or any other entity whether organized for profit or not;

(u) "Quality Assurance Program" means the planned systematic medical and/or management actions which assure consistent rendering of high quality health care services through the use of monitoring and evaluation techniques;

(v) "Service Area" means the defined geographical area (i.e., boundaries of political subdivisions, census tracts, Area Planning and Development Commissions or Health System's Agencies, etc.) in which HMO services are available and readily accessible to enrollees;

(w) "Subscriber" means an enrollee who has entered into a contractual relationship for the provision of/or arrangement of health care services from an HMO for himself and/or his dependents;

(x) "Supplemental Health Services" means those health services offered in addition to "Basic Health Care Services."