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 120-2-92 - INDEPENDENT ACCREDITATION OF HEALTH MAINTENANCE ORGANIZATIONS
Rule 120-2-92-.02 - Qualifications for Approved Accreditation Organizations

Universal Citation: GA Rules and Regs r 120-2-92-.02

Current through Rules and Regulations filed through September 23, 2024

(1) An organization may become an approved accrediting organization for purposes of this regulation when it meets the following requirements:

(a) The organization has been in existence for a minimum of 10 years. An organization in existence for less than 10 years may petition the Commissioner for a waiver of this requirement;

(b) The organization is not owned or operated by a health maintenance organization and performs its accrediting functions independently from the control of health maintenance organizations;

(d) The organization's board of directors is comprised of diverse health care, business and consumer interests, including but not limited to representatives of the medical profession, hospital industry, consumers, and health maintenance organizations;

(e) The organization has a process for regularly reviewing its own accreditation standards for health maintenance organizations;

(f) The organization has provisions to perform regular on-site reviews of health maintenance organizations;

(g) The organization establishes standards for performance and uses those standards to examine and measure the performance of health maintenance organizations in the following areas:

1. Quality Assurance and Improvement

2. Member Satisfaction

3. Appeals Processes

4. Clinical Oversight

5. Provider Credentialing

6. Utilization Review

7. Delegation Oversight

8. Confidentiality of Member Information

9. Access to Services.

(h) A copy of the organization's standards for accreditation must be made available to the Department of Insurance upon request. Revisions to such standards shall also be communicated to the Department. Such standards may be reviewed by the Department of Insurance on a triennial basis. The Department may request additional standards to be included within any approved organization's standards for accreditation.

(i) In each accreditation review, the organization must utilize a physician experienced in health maintenance organization quality assurance management;

(j) Upon request, the Department may review the accreditation review files for a licensed health maintenance organization.

(2) An organization seeking approval as an accrediting organization shall submit evidence to the Commissioner of its compliance with the standards in subparagraph (1) of this section. Upon submission of such evidence, the Commissioner, in his or her discretion, may include the organization on the Approved Accrediting Organizations List.

O.C.G.A. Secs. 33-2-9, 33-21-3, 33-21-18.

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