(1) Applications for certification shall be submitted to the Office of the Commissioner of Insurance on Forms GID-57, GID-65(UR) and GID-72, attached hereto and incorporated herein, along with the original license or certificate fee and application fee required for private review agents under O.C.G.A. 33-8-1.
(2) Private review agents operating in Georgia prior to the effective date of this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance and which have not applied for certification within sixty (60) days of such effective date shall be in violation of Chapter 46 of Title 33 of the Official Code of Georgia Annotated and this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance and are prohibited from operating as a private review agent until such private review agent has applied for certification and has been certified.
(3)
(a) Any private review agent not operating in Georgia on the effective date of this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance may apply for certification at any time prior to doing business in Georgia.
(b) A private review agent or utilization review entity may not conduct utilization review of healthcare services provided in this state unless the Commissioner has granted the private review agent or utilization review entity a certificate pursuant to this chapter.
(4) A certificate shall expire on the second anniversary of its effective date unless renewed, suspended or revoked. Renewal for an additional two (2) year term may be applied for no sooner than ninety (90) days prior to the certification expiration date. Application for renewal shall be submitted on Forms GID-57, GID-65(UR) and GID-72 with the renewal license or certificate fee of $500 required for private review agents under O.C.G.A. §
33-8-1.
(5) On initial application for certification, all advertising materials to be used in Georgia by private review agents shall be filed with the Office of the Commissioner of Insurance.
(6) Each application for certification or renewal must include the following:
(a) A utilization review plan;
(b) Documentation that the private review agent has received full accreditation or certification by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). Reason or reasons should be stated if the organization is not presently fully accredited or certified by URAC or NCQA.
(c) The type, qualifications and number of the personnel, either employed or under contract, to perform the utilization review;
(d) A copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan;
(e) A written description of an ongoing quality assessment program;
(f) The written policies and procedures to ensure that an appropriate representative of the private review agent is reasonably accessible to patients and health care providers five (5) days a week during normal business hours in this State;
(g) The written policies and procedures to ensure that information obtained in the course of utilization review is maintained in a confidential manner. Such policies and procedures shall include, but not be limited to, the following:
1. Assurances that information obtained during the process of utilization review will be kept confidential in accordance with any applicable state or federal laws and regulations;
2. Assurances that the information collected for purposes of utilization review will be limited to the information necessary for the claims administrator to adjudicate the claim and used solely for the purposes of utilization review, quality management, discharge planning and case management;
3. Assurances that information obtained for purposes of utilization review will be shared only with those agents (such as the claims administrator) who have authority to receive such information;
4. Guidelines to prevent unauthorized release of individual enrollee information to the public. Information pertaining to the diagnosis, treatment or health of an enrollee shall be disclosed only to authorized persons. Release of information otherwise shall only be permitted with the express written consent of the covered enrollee, or pursuant to court order for the production of evidence or discovery, or as otherwise provided by state or federal law.
(h) The written policies and procedures establishing and maintaining a complaint system; and
(i) A sample John Doe copy of each type of contract or agreement to be executed between the private review agent and payor, employer, claim administrator, or other entity with certification that the private review agent shall not enter into any incentive payment provision contained in a contract or agreement with a payor which is based on reduction of services or the charges thereof, reduction of length of stay, or utilization or alternative treatment settings to reduce amounts of necessary or appropriate medical care.
