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 120-2-111 - PATIENT'S RIGHT TO INDEPENDENT REVIEW
Rule 120-2-111-.05 - Procedure for Request for Independent Review

(1) In the event that the outcome of the grievance procedure under Code Section 33-20A-5 is adverse to the eligible enrollee, the managed care entity shall include with the written notice of the outcome of the grievance procedure a statement specifying that any request for independent review must be made to the Department on forms made available by the Department in accordance with this Rule, and such forms must be included with the notification. Such statement shall be in simple, clear language in boldface type, which is larger and bolder than any other typeface that is in the notice and in at least 14-point typeface.

(2) An eligible enrollee must submit the written request for independent review to the Department. This request need not be in any required format, but may be a simple written request for an independent review of an adverse outcome of a grievance procedure of a managed care entity. The request must include the name and address of the eligible enrollee, and/or the name and address of the eligible enrollee's guardian in the case of a minor, the eligible enrollee's legal guardian in the case of an eligible enrollee's incapacity, and/or the eligible enrollee's representative. The written request must also include a copy of the notification to the eligible enrollee, or the eligible enrollee's applicable representative, of the adverse outcome determination of the grievance procedure of the managed care entity involved.

(3) Upon receipt of a written request by an eligible enrollee or the eligible enrollee's applicable representative made in accordance with these Rules as outlined above, the Department shall, no later than three (3) working days after receipt, notify the eligible enrollee, or the eligible enrollee's applicable representative, of receipt of the request and assign the request to an independent review organization on a rotating basis according to the date the request was received in accordance with these Rules as outlined below.

(4) Upon assignment of a request for independent review to an independent review organization, the Department shall provide written notification of the name and address of the assigned organization to both the requesting eligible enrollee, or the eligible enrollee's applicable representative, and the managed care entity.