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 120-2-58 - CERTIFICATION OF PRIVATE REVIEW AGENTS
Rule 120-2-58-.02 - Definitions

(1) "Active Practice" means activities including, but not limited to, the review of medical records and charts, participation in utilization review and medical management, evaluating medical necessity, monitoring patient therapy, graduate medical education, or maintenance of board certification.

(2) "Adverse Determination" means a determination based on medical necessity made by a private review agent or utilization review entity not to grant authorization to a hospital, surgical or other facility admission, extension of a hospital stay or other health care service or procedure based on medical necessity or appropriateness.

(3) "Appeal" means a formal request, either orally, or in writing or by electronic transmission, to a private review agent to reconsider a determination not to certify an admission, extension of stay, or other health care service or procedure.

(4) "Authorization" means a determination by a private review agent or utilization review entity that a healthcare service has been reviewed and, based on the information provided, satisfies the utilization review entity's requirements for medical necessity.

(5) "Claim Administrator" means any entity that reviews and determines whether to pay claims to covered persons on behalf of the healthcare plan. Such payment determinations are made on the basis of contract provisions including medical necessity and other factors. Claim administrators may be insurers or their designated review organization, self-insured employers, management firms, third-party administrators, or other private contractors.

(6) "Clinical Criteria" means the written policies, decisions, rules, medical protocols, or guidelines used by a private review agent or utilization review entity to determine medical necessity.

(7) "Clinical Peer" means a healthcare provider who is licensed without restriction or otherwise legally authorized and currently in active practice in the same or similar specialty as that of the treating provider, and who typically manages the medical condition or disease at issue and has knowledge of and experience providing the healthcare service or treatment under review.

(8) "Complaint" is a communication either orally, in writing or by electronic transmission concerning matters related to utilization review including, but not limited to, health care services, denials, accessibility, and confidentiality.

(9) "Concurrent Review" means utilization review conducted during a patient's hospital stay or course of treatment.

(10) "Covered Person" means an individual, including, but not limited to, any subscriber, enrollee, member, beneficiary, participant, or his or her dependent, eligible to receive healthcare benefits by a health insurer pursuant to a healthcare plan or other health insurance coverage.

(11) Emergency healthcare services means healthcare 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:

(12) "Facility" means a hospital, ambulatory surgical center, birthing center, diagnostic and treatment center, hospice, or similar institution. Such term shall not mean a healthcare provider's office.

(13) "Health insurer" or "insurer" means an accident and sickness insurer, care management organization, healthcare corporation, health maintenance organization provider sponsored healthcare corporation, or any similar entity regulated by the Commissioner.

(14) "Healthcare plan" means any hospital or medical insurance policy or certificate, qualified higher deductible health plan, stand-alone dental plan, health maintenance organization or other managed care subscriber contract, the state health benefit plan, or any plan entered into by a care management organization as permitted by the Department of Community Health for the delivery of healthcare services.

(15) "Healthcare service" means healthcare procedures, treatments, or services provided by a facility licensed in this state or provided within the scope of practice of a doctor of medicine, a doctor of osteopathy, or another healthcare provider licensed in this state. Such term includes but is not limited to the provision of pharmaceutical products or services or durable medical equipment.

(16) "Medical necessity" or 'medically necessary' means healthcare services that a prudent physician or other healthcare provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or its symptoms in a manner that is:

(17) "Pharmacy benefits manager" means a person, business entity, or other entity that performs pharmacy benefits management. Such term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a healthcare plan. Such term shall not include services provided by pharmacies operating under a hospital pharmacy license. Such term shall not include health systems while providing pharmacy services for their patients, employees, or beneficiaries, for indigent care, or for the provision of drugs for outpatient procedures. Such term shall not include services provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or a licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies which are licensed under Code Section 26-4-110.

(18) "Prior authorization" means any written or oral determination made at any time by a claim administrator or an insurer, or any agent thereof, that a covered person's receipt of healthcare services is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such services have been satisfied. The term 'agent' as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.

(19) "Private review agent" means any person or entity which performs utilization review for:

(20) "Reconsideration" means a request either orally, in writing or by electronic transmission to the private review agent to reconsider an adverse determination.

(21) "Review Criteria" means the written policies, decisions, rules, medical protocols or guidelines used by the private review agent to determine medical necessity or appropriateness.

(22) "Urgent healthcare service" means a healthcare service with respect to which the application of the time periods for making a nonexpedited prior authorization, which, in the opinion of a physician or other healthcare provider with knowledge of the covered person's medical condition:

(23) "Utilization review entity" means an insurer or other entity that performs prior authorization for one or more of the following entities:

(24) "Utilization Review Determination" means a recommendation by a private review agent regarding medical necessity or appropriateness of the health care services given or proposed to be given to a patient.