Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-10 - REGULATIONS REGARDING INSURANCE CONTRACT
Rule 120-2-10-.03 - Medical or Surgical Policies-Outpatient Coverage

(1) In accordance with Section 33-29-6 of the Georgia Insurance Code this rule is applicable to all individual accident and sickness policies that provide coverage for medical or surgical procedures which are required to be performed on an inpatient basis at a licensed hospital. These policies shall contain provisions on their face or by endorsement to reimburse policyholders for any otherwise covered medical or surgical procedures when such procedures are performed on an outpatient basis in a facility described in said policies.

(2) In ordinary circumstances when the general condition of the patient would not be placed in jeopardy, admission to the hospital as a registered bed patient may not be necessary for the sole purpose of performing the procedures described herein.

(3) All personnel and providers of services shall be currently licensed to perform the services they provide, when such services require licensure or registration under applicable State laws.

(4) All facilities and equipment needed and used for and in the delivery of services which are required to be licensed and/or certified by law shall be so licensed and/or certified.

(5) The medical or surgical procedures listed in paragraph (7) below may be performed on an outpatient basis unless the following situations exist which may contraindicate the use of an outpatient setting:

(6) Upon the certification by the Commissioner of Human Resources to the Insurance Commissioner that any procedure listed in paragraph (7) below can no longer be legally and safely performed on an outpatient basis, the Insurance Commissioner shall issue an order suspending the listing of that procedure(s). Such suspension shall remain in effect until such time as the Commissioner of Human Resources certifies to the Insurance Commissioner that the procedure(s) so suspended may again be legally and safely performed on an outpatient basis at which time the Insurance Commissioner shall issue an order reinstating the listing of that procedure(s). A copy of any such suspension and reinstatement orders shall be kept at the offices of the Insurance Commissioner and provided at cost to any person informing the Insurance Commissioner in writing of their desire to receive copies of all such orders. The procedures listed as of the time of their performances shall be reimbursable even if suspended at a subsequent date.

(7) The numbers as set forth below in the following subparagraphs represent the medical and surgical services and procedures as contained in the Physician's Current Procedural Terminology (CPT), Fourth Edition, 1977, as published by the American Medical Association, Chicago, Illinois, 60610. Subject to the above listed conditions, these listed procedures may be performed on an outpatient basis.