(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.
