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 120-2-106 - SURPRISE BILLING
Rule 120-2-106-.03 - Definitions

(1) "Balance bill" means the amount that a non-participating provider charges for services provided to a covered person. Such amount equals the difference between the amount paid or offered by the insurer and the amount of the non-participating provider's bill charge but shall not include any amount for coinsurance, copayments, or deductibles due by the covered person.

(2) "Contracted amount" means the median in-network amount paid during the 2017 calendar year by an insurer for the emergency or non-emergency services provided by in-network providers engaged in the same or similar specialties and provided in the same or nearest geographical area. The Department shall annually adjust such amount for inflation, which may be based on the Consumer Price Index, and shall not include Medicare or Medicaid rates.

(3) "Covered person" means an individual who is insured under a healthcare plan.

(4) "Emergency medical provider" means any physician licensed by the Georgia Composite Medical Board who provides emergency medical services and any other healthcare provider licensed or otherwise authorized in this state to render emergency medical services.

(5) "Emergency medical services" means medical services rendered after the recent onset of a medical or traumatic condition, sickness, or injury exhibiting acute symptoms of sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:

(6) "Facility" means a hospital, an ambulatory surgical treatment center, birthing center, diagnostic and treatment center, hospice, or similar institution.

(7) "Geographic area" is defined as one of 16 Geo Rating Areas established for ACA purposes by use of Georgia Standardized Metropolitan Statistical Areas, expanded by contiguous counties and which has been in required use by Georgia insurers since 2014.

(8) "Healthcare plan" means any hospital or medical insurance policy or certificate, healthcare plan contract or certificate, qualified higher deductible health plan, health maintenance organization or other managed care subscriber contract, or state healthcare plan. This term shall not include limited benefit insurance policies or plans listed under paragraph (3) of Code Section 33-1-2, air ambulance insurance, or policies issued in accordance with Chapter 21A or 31 of this title or Chapter 9 of Title 34, relating to workers' compensation, Part A, B, C, or D of Title XVIII of the Social Security Act (Medicare), or any plan or program not described in this paragraph over which the Commissioner does not have regulatory authority. Notwithstanding paragraph (3) of Code Section 33-1-2 and any other provision of this title, this chapter this term shall include stand-alone dental insurance and stand-alone vision insurance for purposes of this chapter.

(9) "Healthcare provider" or "provider" means any physician, other individual, or facility other than a hospital licensed or otherwise authorized in this state to furnish healthcare services, including, but not limited to, any dentist, podiatrist, optometrist, psychologist, clinical social worker, advanced practice registered nurse, registered optician, licensed professional counselor, physical therapist, marriage and family therapist, chiropractor, athletic trainer qualified pursuant to Code Section 43-5-8, occupational therapist, speech-language pathologist, audiologist, dietitian, or physician assistant.

(10) "Healthcare services" means emergency or non-emergency medical services.

(11) "Insurer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including those of an accident and sickness insurance company, a health maintenance organization, a healthcare plan, a managed care plan, or any other entity providing a health insurance plan, a health benefit plan, or healthcare services.

(12) "Median" means the middle number of a sorted list of reimbursement amounts paid to in-network providers or facilities with respect to a specific emergency or non-emergency medical service, with each paid claim amount separately represented on the list, arranged in order from least to greatest. If there is an even number of items in the sorted list of paid claim amounts, the median is found by taking the average of the two middlemost numbers. The calculated median paid amount shall include copayment, coinsurance, and deductible as applicable and shall exclude claims in which the insurer is not the primary payer.

(13) "Non-emergency medical services" means the examination or treatment of persons for the prevention of illness or the correction or treatment of any physical or mental condition resulting from an illness, injury, or other human physical problem which does not qualify as an emergency medical service and includes, but is not limited to:

(14) "Out-of-network" refers to healthcare services provided to a covered person by providers or facilities who do not belong to the provider network in the healthcare plan.

(15) "Non-participating provider" means a healthcare provider who has not entered into a contract with a healthcare plan for the delivery of medical services.

(16) "Participating provider" means a healthcare provider that has entered into a contract with an insurer for the delivery of healthcare services to covered persons under a healthcare plan.

(17) "Resolution organization" means a qualified, independent, third-party claim dispute resolution entity selected by and contracted with the Department.

(18) "State healthcare plan" means:

(19) "Surprise bill" means a bill resulting from an occurrence in which charges arise from a covered person receiving healthcare services from an out-of-network provider at an in-network facility.