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-.05 - Requirements for Utilization Review

Universal Citation: GA Rules and Regs r 120-2-58-.05

Current through Rules and Regulations filed through March 20, 2024

(1) Private review agents shall have sufficient staff to facilitate review in accordance with review criteria and shall designate one or more individuals able to effectively communicate medical and clinical information.

(2) Private review agent shall provide access to its review staff by a toll free or collect call telephone line during normal business hours. A private review agent shall have an established procedure to review timely call backs from health care providers and shall establish written procedures for receiving after-hour calls, either in person or by recording.

(3) Private review agent shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services. All requests for information shall be made during normal business hours.

(4) Private review agents shall identify themselves prior to collecting necessary information.

(5) Private review agents shall establish and follow procedures and rules for on-site medical facility review.

(6) In the event a private review agent questions the medical necessity or appropriateness of care, the following procedures will apply:

(a) The attending health care provider shall have the opportunity to discuss a utilization review determination promptly by telephone with a clinical peer, an identified health care provider representing the private review agent and trained in a related healthcare specialty. If the determination is made not to certify, an adverse determination exists.

(b) Reconsideration of an adverse determination occurs when any questions concerning medical necessity or appropriateness of care are not resolved under subparagraph (a) above. The right to appeal an adverse determination shall be available to the enrollee and the attending physician or other ordering health care provider. The enrollee or enrollee's representative shall be allowed a second review by another identified health care provider in an appropriate medical specialty who represents the private review agent.

(7) The private review agent shall have written procedures for providing notification of its determinations regarding all forms of certification in accordance with the following:

(a) When an initial determination is made to certify, notification shall be provided promptly either by telephone, in writing or electronic transmission to the attending health care provider, the facility rendering service as well as to the enrollee. Written notification shall be transmitted within two (2) business days of the determination.

(b) When a determination is made not to certify, the attending physician and/or other ordering health care provider or facility rendering service shall:
1. Be notified by telephone within one (1) business day.

2. Be sent a written notification within one (1) business day, which also shall be sent to the enrollee. The written notification shall include: principal reason(s) for the determination and instructions for initiating an appeal of the adverse determination.

(c) The private review agent shall establish procedures for appeals to be made in writing and by telephone. The private review agent shall notify the health care provider and enrollee in writing of its determination on the appeal as soon as possible, but in no case later than sixty (60) days after receiving the required documentation to conduct the appeal.

(d) The appeals procedure does not preclude the right of an enrollee to pursue legal action.

O.C.G.A. §§ 33-2-9, 33-46-1, 33-46-11.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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