Compilation of Rules and Regulations of the State of Georgia, Subject 120-2-58, Rule 120-2-58-.09 - Severability Provision | Compilation of Rules and Regulations of the State of Georgia

1. Submit all applicable organizational documents including an organizational chart. The following documents MUST BE an original copy or a certified copy of the original: partnership agreement; articles of incorporation certified by your Secretary of State; trade name certificate; trust agreement; any other applicable documents; and all amendments to those documents.

2. Provide one copy of the bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal.

3. List the names, addresses, and official titles of positions held by individuals who are responsible for the conduct of the affairs of the private review agent in Georgia.

4. Submit one copy of the Biographical Affidavit on Form GID-65(UR) for each of the persons listed in item 3.

5. Indicate if the private review agent plans to utilize a fictitious or "dba" name. If so, attach a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business.

6. Submit all other items required under Rule 120-2-58-.03(6).

DIRECTIONS FOR ATTESTING TO THIS APPLICATION:

a. If applicant is a sole proprietor, the application must be sworn by the sole proprietor.

b. If applicant is a partnership, the application must be sworn by the principal partners or by all officers and directors.

c. If applicant is a corporation, the application must be sworn by the president and secretary.

==============================================================

THE FOLLOWING ATTESTATION FORM SHALL BE USED:

I do solemnly swear or affirm that I am familiar with the Laws of Georgia relating to Private Review Agents; that I have complied with all of the requirements of O.C.G.A. §§ 33-46-4., 33-46-5 and Chapter 39 of Title 33 of the Official Code of Georgia Annotated; that all the foregoing information and documentary evidence submitted is true, complete, and correct to the best of my knowledge and belief. I understand that my certification is subject to administrative action if false information is contained herein.

_____________________________

Organization

_____________________________

Signature of Affiant

_____________________________

Name (typewritten)

_____________________________

Title (typewritten)

Sworn to and subscribed before me this___________day of________,19___________.

_______________________________________

(Notary Public)

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

Biographical Affidavit

(Typewritten Only)

If you are an individual with a disability and wish to acquire this affidavit in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031. Full Name and Address of Private Review Agent (Do Not Use Group Names).

_________________________________________________

In connection with the above-named private review agent, I herewith make representations and supply information about myself as herein-after set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS "NO" or "NONE", SO STATE.

1. Affiant's Full Name (Initials Not Acceptable)._______________

_______________________________________________

2.

a. Have you ever had your name changed? - If yes, give the reason for the change.____________________

_______________________________________________

b. Other names used at any time

________________________________________________

3. Affiant's Business Address_____________

_______________________________________________

4. Present or Proposed Position with the Applicant Organization

_______________________________________________

5. Present employer may be contacted.

Yes No (Circle One)

6. List any professional licenses issued by any public or governmental licensing agency or regulatory authority which you presently hold or have held in the last ten (10) years (state date license issued, issuer of license, date terminated, reasons for termination).

_______________________________________________

7. Has the certificate of authority or license to do business of any private review agent of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position?

________________________If yes, give details:

_______________________________________________

Dated and signed this_________________day of_____________at

___________________. I hereby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.

___________________________________

(Signature of Affiant)

State of_______________________________________County of_______________________________________Personally appeared before me the above named____________________personally known to me, who, being duly sworn, deposes and says that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief.

Subscribed and sworn to before me this_______________day of ______________________ 19_______.

_______________________

(Notary Public)

(SEAL) My Commission Expires _______________

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

CHECKLIST OF APPLICATION DOCUMENTS

FOR CERTIFICATION OF PRIVATE REVIEW AGENTS

Name of organization:_______________________________________

(Please file your documents in the same order as the checklist) (check or n/a)

______1. Are all applicable organizational documents (original copy or certified copy of the original) including all amendments to those documents attached?

______a. Partnership Agreement

______b. Articles of Incorporation (certified by your Secretary of State)

______c. Trade Name Certificate

______d. Trust Agreement

______e. Other ______________________

______2. Are the bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal attached?

______3. Is one copy of the Biographical Affidavit (GID-65(UR)) for each of the individuals responsible for the conduct of the affairs of the private review agent attached?

______4. Is the private review agent using a fictitious or "dba" name? If so, is a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business attached?

______5. Was the private review agent operating in Georgia prior to the effective date of this Regulation?

______yes______no

If so, was the certification applied for within sixty (60) days of such effective date?

______yes______no

______6. Have the original license or certificate fee and application fee been enclosed? (Please make checks payable to the Commissioner of Insurance)

______7. If a renewal, was it applied for no sooner than ninety (90) days prior to the certification expiration date?

______a. Was the application for renewal submitted on Forms GID-57, GID-65(UR) and GID- 72?

______b. Has the renewal license or certificate fee been received?

______8. Is the utilization review plan attached?

______9. Is a statement or documentation that the private review agent has received full accreditation by URAC attached?

______10. If your organization is not fully accredited by URAC, have you attached the reasons why full accreditation has not been obtained?

______11. Is a description of the type, qualifications and number of the personnel, either employed or under contract, to perform utilization review attached?

______12. Is a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan attached?

______13. Is a written description of an ongoing quality assessment program attached?

______14. Are the written policies and procedures to ensure that a representative of the private review agent is reasonably accessible to patients and providers five (5) days a week during normal business hours in this state attached?

______15. Are the written policies and procedures to ensure compliance with all state laws and regulations to protect the confidentiality of information obtained in the course of utilization review attached?

______16. Are the written policies and procedures for establishing and maintaining a complaint system attached?

______17. Is 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 no incentive payment provision exists in these contracts or agreements for the private review agent based on reduction of services or the charges thereof, reduction of length of stay, or utilization of alternative treatment settings to reduce amounts of necessary or appropriate medical care attached?

______18. Is the Application for Certification as a Private Review Agent Form GID- 57 completed and attached?

______19. Are the Biographical Affidavits on Form GID-65(UR) completed and attached?

______20. Is the Checklist of Application Documents Form GID-72 completed and attached?

______21. Are all the appropriate areas in the application signed and notarized or certified? If you are an individual with a disability and wish to acquire this document in an alternative format, please contact the ADA Coordinator, Office of Commissioner of insurance, 2 Martin Luther King, Jr., Dr., Atlanta, Georgia 30334. (404) 656-2056 - TDD (404) 656-4031.

OFFICE OF COMMISSIONER OF INSURANCE STATE OF GEORGIA

ATLANTA, GEORGIA

ANNUAL REPORT INFORMATION FOR UTILIZATION

REVIEW ACTIVITIES

FOR THE YEAR ENDED ___________

(Typewritten Only)

If you are an individual with a disability and wish to acquire this application in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King, Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031 This information is necessary for the annual report which is required under O.C.G.A. Section 33- 46-14 to assess utilization review operations and the extent to which these practices actually affect patients in Georgia. This form is distributed to each private review agent. The information obtained will be summarized providing an overall picture of the "State of Utilization Review in Georgia."

1. Legal name and address of private review agent:

__________________________________________________

2. Telephone number: (___)______________

Fax number: (__)_______________

3. Name, title and phone number of designated contact person responsible for this information:

__________________________________________________

4. Indicate the year in which your organization was established:________Indicate the year in which your organization began operations in Georgia:________

5. Is your organization independently owned or is it a subsidiary of or owned by another organization? Independently owned_______(SKIP TO NEXT SECTION)

A subsidiary of or owned by another organization________

6. Does the parent organization or any of its subsidiaries provide direct patient care?

yes________no______

7. Is the parent organization or any of its subsidiaries a health insurer?

yes______no_______

8. Has the parent organization or any of its subsidiaries ever purchased any of your utilization review services?

yes______no______

1. Indicate the estimated percentage distribution of clinical services reviewed:

2. Indicate the total acute care hospital admissions reviewed:

___________________________________

3. Indicate the percent of proposed admissions diverted for outpatient care:

___________________________________

4. Indicate the volume of reviews annually performed: prospective (precertification) _________________concurrent (continued stay) _________________ retrospective_________________ other _________________

5. Indicate the total number of Georgia lives covered for each entity for whom the private review agent performs utilization review services:

Entity # Georgia lives covered

a. Employers _________________

b. Payors (Insurers) _________________

c. Claim administrators _________________

d. Others _________________

6. Indicate if your organization performs the following types of review and the percentage performed telephonically and/or on-site;

Telephonic On site

Prospective Review yes no______%______%

Concurrent Stay Review yes no______%______%

Discharge Planning yes no______%______%

Case Management yes no______%______%

7. How many reviews does your organization conduct on average, per episode of care?

prospective ______

concurrent______

retrospective______

other______

1. Personnel who conduct reviews.

(A) For each type, please indicate if, at any phase of the utilization review process, any of that staff type made decisions about the necessity or the appropriateness of requested medical or surgical care for your organization for the preceding calendar year.

(B) If "yes," please enter the total number of staff of each type that made these decisions, and the number of staff that were full-time employees of your organization, part-time employees of your organization who worked on the premises of your organization, part-time employees of your organization who worked off the premises of your organization, and consultants/advisors to your organization. (IF NONE, ENTER "o")

Form GID-73

2. List the board specialties (as recognized by the American Board of Medical Specialists) for the number of staff physicians and the number of consultants/advisors for the organization. (i.e. Family Practice, Internal Medicine, Pediatrics, etc.) Also, indicate the same for staff recognized by the Advisory Board of Osteopathic Specialist.

1. CASE MANAGEMENT

a. During the preceding calendar year, did your organization review any catastrophic medical or surgical cases to determine the need for case management services; that is, determine the need for coordinated care for patients requiring expensive or extended care?

yes_________________________no_________________________ (SKIP TO QUESTION 2)

b. How many cases did you screen for case-management?_________________________

c. How many of these cases were recommended for case-management?

________________________________________

d. How many were ultimately case-managed?

________________________________________

2. Please list the top five surgeries or procedures that your organization most often did not authorize during the preceding calendar year because of unsubstantiated medical need.

________________________________________

3. Indicate the number and outcome by clinical service (i.e. medical, surgical, maternity, etc.) of each appeal as addressed in Rule 120-2-58-.05, entitled "Requirements for Utilization Review", paragraph (6)(b).

________________________________________

4. The average number of days required to complete each level of appeal:

________________________________________

ACKNOWLEDGEMENT

The Office of Commissioner of Insurance expresses its gratitude and appreciation to the United States General Accounting Office for granting permission to use some material from their study entitled "Information on Utilization Review Organizations." GAO/HRD-93-22FS.