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-.08 - Policies and Procedures of the HMO

Universal Citation: GA Rules and Regs r 111-8-29-.08

Current through Rules and Regulations filed through September 23, 2024

The HMO shall have written policies and procedures governing the provision of services which are based on the stated objectives of the HMO. Policies and procedures shall be approved by the governing body and reviewed and updated at least annually. All policies/procedures shall be available for review by staff, enrollees, and providers. Policies and procedures shall include the following subjects:

(a) Administrative Policies:

1. Advisory Panels. Enrollees shall be afforded an opportunity to participate in health care matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decision, or through the use of other mechanisms;

2. Complaint System. The HMO shall establish and maintain a complaint system approved by the Insurance Commissioner after consultation with the Commissioner;

3. Annual Report. The HMO shall annually, on/or before the first day of March, file with the Insurance Commissioner's Office an annual statement as of December 31st of the preceding year which has been certified by at least two principal officers of said HMO. This report shall include summary information and statistics relating to the quality of health care, cost of operations, the pattern of utilization of services, availability and accessibility to services, use of the complaint system, and such other matters as may be required by the Commissioner;

4. Separation of Medical Decisions. The HMO plan shall be able to demonstrate through its quality assurance program and utilization review process that medical decisions are not hindered by fiscal and administrative management;

5. Service Area. The HMO shall maintain a current, explicit, definition of its service area and a statement of any restrictions or limitations on out-of-area health care.

(b) Policies Related to Professional Services:

1. Physician Services. The enrollee shall have a choice of any of the primary care physicians under contract to the HMO subject to availability;

2. Other Services. A system shall be established for referral, consultant, and other services not directly provided by the HMO to ensure continuity and availability of care;

3. Inpatient Admission and Discharge Policies. The HMO shall have policies and procedures for inpatient health facility utilization and utilization review.

Ga. L. 1964, pp. 499, 507, 523; Ga. L. 1979, pp. 1148, 1153, 1157, 1159, 1160, 1161; O.C.G.A. § 33-21-1et seq.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.