reglab/housing_qa huggingface dataset:
GA Code § 33-20A-9 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 1 - Patient Protection|§ 33-20A-9. Emergency Services Requirements; Restrictive Formulary Requirements

 Every managed care plan shall include provisions that:      In the event that a patient seeks emergency services and if necessary in the opinion of the emergency health care provider responsible for the patient's emergency care and treatment and warranted by his or her evaluation, such emergency provider may initiate necessary intervention to stabilize the condition of the patient without seeking or receiving prospective authorization by the managed care entity or managed care plan. No managed care entity or private health benefit plan may subsequently deny payment for an evaluation, diagnostic testing, or treatment provided as part of such intervention for an emergency condition. For purposes of this Code section, the term "emergency health care provider" includes without limitation an emergency services provider and a licensed ambulance service providing 911 emergency medical transportation.   No managed care entity or private health benefit plan which has given prospective authorization after the stabilization of a person's condition for an evaluation, diagnostic testing, or treatment may subsequently deny payment for the provision of such evaluation, diagnostic testing, or treatment. An acknowledgment of an enrollee's eligibility for benefits by the managed care entity or private health benefit plan shall not, by itself, be construed as a prospective authorization for the purposes of this Code section.   If in the opinion of the emergency health care provider, a patient's condition has stabilized and the emergency health care provider certifies that the patient can be transported to another facility without suffering detrimental consequences or aggravating the patient's condition, the patient may be relocated to another facility which will provide continued care and treatment as necessary; and     When a managed care plan uses a restrictive formulary for prescription drugs, such use shall include a written procedure whereby patients can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when:   The formulary's equivalent has been ineffective in the treatment of the patient's disease or condition; or   The formulary's drug causes or is reasonably expected to cause adverse or harmful reactions in the patient.       (Code 1981, §33-20A-9, enacted by Ga. L. 1996, p. 485, § 1; Ga. L. 1997, p. 908, § 2; Ga. L. 1999, p. 350, § 2; Ga. L. 2006, p. 652, § 3/HB 1257.)   Cross references.   - Evaluation of persons with emergency conditions, § 31-11-82.
GA Code § 33-20A-10 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 1 - Patient Protection|§ 33-20A-10. Chapter Inapplicable to Workers' Compensation Provisions

 Nothing in this article shall apply to Chapter 9 of Title 34, relating to workers' compensation.    (Code 1981, §33-20A-10, enacted by Ga. L. 1996, p. 485, § 1; Ga. L. 1999, p. 350, § 2.)
GA Code § 33-20A-30 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-30. Short Title

 This article shall be known and may be cited as the "Patient's Right to Independent Review Act."    (Code 1981, §33-20A-30, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)   Law reviews.   - For note on 1999 amendments to Code sections in this article, see 16 Ga. St. U.L. Rev. 151 (1999).
GA Code § 33-20A-32 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-32. Right to Appeal

 An eligible enrollee shall be entitled to appeal to an independent review organization when:    The eligible enrollee has received notice of an adverse outcome pursuant to a grievance procedure or the managed care entity has not complied with the requirements of Code Section 33-20A-5 with regard to such procedure; or   A managed care entity determines that a proposed treatment is excluded as experimental under the managed care plan, and all of the following criteria are met:   The eligible enrollee has a terminal condition that, according to the treating physician, has a substantial probability of causing death within two years from the date of the request for independent review or the eligible enrollee's ability to regain or maintain maximum function, as determined by the treating physician, would be impaired by withholding the experimental treatment;   After exhaustion of standard treatment as provided by the evidence of coverage or a finding that such treatment would be of substantially lesser or of no benefit, the eligible enrollee's treating physician certifies that the eligible enrollee has a condition for which standard treatment would not be medically indicated for the eligible enrollee or for which there is no standard treatment available under the evidence of coverage of the eligible enrollee more beneficial than the treatment proposed;   The eligible enrollee's treating physician has recommended and certified in writing treatment which is likely to be more beneficial to the eligible enrollee than any available standard treatment;   The eligible enrollee has requested a treatment as to which the eligible enrollee's treating physician, who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the eligible enrollee's condition, has certified in writing that scientifically valid studies using accepted protocols, such as control group or double-blind testing, published in peer reviewed literature, demonstrate that the proposed treatment is likely to be more beneficial for the eligible enrollee than available standard treatment; and   A specific treatment recommended would otherwise be included within the eligible enrollee's certificate of coverage, except for the determination by the managed care entity that such treatment is experimental for a particular condition.       (Code 1981, §33-20A-32, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-33 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-33. Minimum Expense of Treatment Prior to Review

 Except where required pursuant to Code Section 51-1-49, a proposed treatment must require the expenditure of a minimum of $500.00 to qualify for independent review.    (Code 1981, §33-20A-33, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-34 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-34. Representatives for Enrollee; Cost of Review; Cooperation

  The parent or guardian of a minor who is an eligible enrollee may act on behalf of the minor in requesting independent review. The legal guardian or representative of an incapacitated eligible enrollee shall be authorized to act on behalf of the eligible enrollee in requesting independent review. Except as provided in Code Section 51-1-49, independent review may not be requested by persons other than the eligible enrollee or a person acting on behalf of the eligible enrollee as provided in this Code section.   A managed care entity shall be required to pay the full cost of applying for and obtaining the independent review.   The eligible enrollee and the managed care entity shall cooperate with the independent review organization to provide the information and documentation, including executing necessary releases for medical records, which are necessary for the independent review organization to make a determination of the claim.     (Code 1981, §33-20A-34, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-35 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-35. Request for Independent Review

  In the event that the outcome of the grievance procedure under Code Section 33-20A-5 is adverse to the eligible enrollee, the managed care entity shall include with the written notice of the outcome of the grievance procedure a statement specifying that any request for independent review must be made to the department on forms developed by the department, and such forms shall be included with the notification. Such statement shall be in simple, clear language in boldface type which is larger and bolder than any other typeface which is in the notice and in at least 14 point typeface.   An eligible enrollee must submit the written request for independent review to the department. Instructions on how to request independent review shall be given to all eligible enrollees with the written notice required under this Code section together with instructions in simple, clear language as to what information, documentation, and procedure are required for independent review.   Upon receipt of a completed form requesting independent review as required by subsection (a) of this Code section, the department shall notify the eligible enrollee of receipt and assign the request to an independent review organization on a rotating basis according to the date the request is received.   Upon assigning a request for independent review to an independent review organization, the department shall provide written notification of the name and address of the assigned organization to both the requesting eligible enrollee and the managed care entity.   No managed care entity may be certified by the Commissioner under Article 1 of this chapter unless the entity agrees to pay the costs of independent review to the independent review organization assigned by the department to conduct each review involving such entity's eligible enrollees.     (Code 1981, §33-20A-35, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-36 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-36. Additional Information Required for Independent Review

  Within three business days of receipt of notice from the department of assignment of the application for determination to an independent review organization, the managed care entity shall submit to that organization the following:   Any information submitted to the managed care entity by the eligible enrollee in support of the eligible enrollee's grievance procedure filing;   A copy of the contract provisions or evidence of coverage of the managed care plan; and   Any other relevant documents or information used by the managed care entity in determining the outcome of the eligible enrollee's grievance.  Upon request, the managed care entity shall provide a copy of all documents required by this subsection, except for any proprietary or privileged information, to the eligible enrollee. The eligible enrollee may provide the independent review organization with any additional information the eligible enrollee deems relevant.      The independent review organization shall request any additional information required for the review from the managed care entity and the eligible enrollee within five business days of receipt of the documentation required under this Code section. Any additional information requested by the independent review organization shall be submitted within five business days of receipt of the request, or an explanation of why the additional information is not being submitted shall be provided.   Additional information obtained from the eligible enrollee shall be transmitted to the managed care entity, which may determine that such additional information justifies a reconsideration of the outcome of the grievance procedure. A decision by the managed care entity to cover fully the treatment in question upon reconsideration using such additional information shall terminate independent review.   The expert reviewer of the independent review organization shall make a determination within 15 business days after expiration of all time limits set forth in this Code section, but such time limits may be extended or shortened by mutual agreement between the eligible enrollee and the managed care entity. The determination shall be in writing and state the basis of the reviewer's decision. A copy of the decision shall be delivered to the managed care entity, the eligible enrollee, and the department by at least first-class mail.   The independent review organization's decision shall be based upon a review of the information and documentation submitted to it.   Information required or authorized to be provided pursuant to this Code section may be provided by facsimile transmission or other electronic transmission.     (Code 1981, §33-20A-36, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-37 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-37. Effect of Favorable Determinations

  A decision of the independent review organization in favor of the eligible enrollee shall be final and binding on the managed care entity and the appropriate relief shall be provided without delay. A managed care entity bound by such decision of an independent review organization shall not be liable pursuant to Code Section 51-1-48 for abiding by such decision. Nothing in this Code section shall relieve the managed care entity from liability for damages proximately caused by its determination of the proposed treatment prior to such decision.   A determination by the independent review organization in favor of a managed care entity shall create a rebuttable presumption in any subsequent action that the managed care entity's prior determination was appropriate.   In the event that, in the judgment of the treating health care provider, the health condition of the enrollee is such that following the provisions of Code Section 33-20A-36 would jeopardize the life or health of the eligible enrollee or the eligible enrollee's ability to regain maximum function, as determined by the treating health care provider, an expedited review shall be available. The expedited review process shall encompass all elements enumerated in Code Sections 33-20A-36 and 33-20A-40; provided, however, that a decision by the expert reviewer shall be rendered within 72 hours after the expert reviewer's receipt of all available requested documents.     (Code 1981, §33-20A-37, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140; Ga. L. 2011, p. 99, § 46/HB 24.)   Editor's notes.   - Ga. L. 2011, p. 99, § 101/HB 24, not codified by the General Assembly, provides that the amendment to this Code section by that Act shall apply to any motion made or hearing or trial commenced on or after January 1, 2013.   Law reviews.   - For article, "Evidence," see 27 Ga. St. U.L. Rev. 1 (2011). For article on the 2011 amendment of this Code section, see 28 Ga. St. U.L. Rev. 1 (2011).
GA Code § 33-20A-38 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-38. Organizational and Employee Liability

 Neither an independent review organization nor its employees, agents, or contractors shall be liable for damages arising from determinations made pursuant to this article, unless an act or omission thereof is made in bad faith or through gross negligence, constitutes fraud or willful misconduct, or demonstrates malice, wantonness, oppression, or that entire want of care which would raise the presumption of conscious indifference to the consequences.    (Code 1981, §33-20A-38, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)   Code Commission notes.   - Pursuant to Code Section 28-9-5, in 1999, "an" was inserted near the beginning of this Code section.
GA Code § 33-20A-40 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-40. Determining Medical Necessity or Whether a Treatment Is Experimental

  For the purposes of this article, in making a determination as to whether a treatment is medically necessary and appropriate, the expert reviewer shall use the definition provided in paragraph (7) of Code Section 33-20A-31.   For the purposes of this article, in making a determination as to whether a treatment is experimental, the expert reviewer shall determine:   Whether such treatment has been approved by the federal Food and Drug Administration; or   Whether medical and scientific evidence demonstrates that the expected benefits of the proposed treatment would be greater than the benefits of any available standard treatment and that the adverse risks of the proposed treatment will not be substantially increased over those of standard treatments.  For either determination, the expert reviewer shall apply prudent professional practices and shall assure that at least two documents of medical and scientific evidence support the decision.        (Code 1981, §33-20A-40, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-41 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-41. Rules and Regulations

 The department shall provide necessary rules and regulations for the implementation and operation of this article.    (Code 1981, §33-20A-41, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-42 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 2 - Patient's Right to Independent Review|§ 33-20A-42. Grievance Procedures and Hearings for Medicaid Care Management Members

 Medicaid care management members shall, after first exhausting the grievance procedure of the managed care plan providing health care benefits pursuant to Article 7 of Chapter 4 of Title 49 or Article 13 of Chapter 5 of Title 49, be afforded the fair hearing rights provided pursuant to Code Section 49-4-153 or the state plan provided for in Article 13 of Chapter 5 of Title 49.    (Code 1981, §33-20A-42, enacted by Ga. L. 2005, p. 1438, § 2/SB 140.)
GA Code § 33-20A-60 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 3 - Managed Health Care Plans|§ 33-20A-60. Definitions

 As used in this article, the term:    "Agent" shall not include an agent or agency as defined in Code Section 33-23-1.   "Carrier" means an accident and sickness insurer, fraternal benefit society, health care corporation, health maintenance organization, provider sponsored health care corporation, or any similar entity and any self-insured health benefit plan not subject to the exclusive jurisdiction of the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq., which entity provides for the financing or delivery of health care services through a health benefit plan, or the plan administrator of any health benefit plan established pursuant to Article 1 of Chapter 18 of Title 45.   "Claimant" means any provider, facility, or individual making a claim under a health benefit plan on behalf of an enrollee.   "Enrollee" has the same meaning as provided in Code Section 33-20A-3.   "Health benefit plan" has the same meaning as provided in Code Section 33-24-59.5.   "Physician contract" means any contract between a physician and a carrier or a carrier's network, physician panel, intermediary, or representative providing the terms under which the physician agrees to provide health care services to an enrollee pursuant to a health benefit plan.   "Postpayment audit" means an investigation by a health benefit plan, carrier, insurer, or panel, or agent thereof, of whether a claim was properly paid to a claimant.   "Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a claimant with respect to a claim, or any portion thereof, by requiring repayment of such payments, by reducing other payments owed to the claimant, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the claimant.     (Code 1981, §33-20A-60, enacted by Ga. L. 2002, p. 441, § 9; Ga. L. 2003, p. 140, § 33; Ga. L. 2019, p. 337, § 1-90/SB 132.)    The 2019 amendment,  effective July 1, 2019, deleted "as used in this article" preceding "shall not include" in paragraph (1); deleted "hospital service corporation, medical service corporation," following "fraternal benefit society," in paragraph (2); deleted former paragraph (4), which read: " 'Commissioner' means the Commissioner of Insurance."; redesignated former paragraphs (5) through (9) as present paragraphs (4) through (8), respectively; and, in paragraph (8), deleted "currently" following "other payments".   Editor's notes.   - For short title and applicability, see the Editor's notes at the beginning of this article.   Law reviews.   - For note on the 2002 enactment of this Code section, see 19 Ga. St. U.L. Rev. 220 (2002).
GA Code § 33-20A-70 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 20A - Managed Health Care Plans|Article 4 - Joint Committee to Study Prescription Costs in State Funded Health Care Plans|§ 33-20A-70. Creation; Members; Meetings; Duties; Cooperation by the Department of Community Health; Members' Expenses; Repealer

 Repealed by Ga. L. 2005, p. 1438, § 1/SB 140, effective December 31, 2005.   Editor's notes.   - This article was based on Code 1981, § 33-20A-70, enacted by Ga. L. 2005, p. 1438, § 1/SB 140.
GA Code § 33-23-1.1 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 23 - Licensing|Article 1 - Agents, Agencies, Subagents, Counselors, and Adjusters|§ 33-23-1.1. Counselor's Additional Ancillary Services Considered a Separate Transaction

 As used in paragraph (6) of subsection (a) of Code Section 33-23-1, the definition of counselor, the term "transaction" refers to coverage or services in the same line or subline of insurance; provided, however, that additional ancillary services for commercial risks in excess of acquisition services shall be considered a separate transaction when such additional ancillary services are disclosed in writing to the insured and approved in advance by the insured. Additional ancillary services shall include, but not be limited to, the following: risk identification; loss measurement; gathering and analysis of loss information; verification of workers' compensation experience modifiers; setting of risk retention levels; development of retention financing plans; development of insurance specifications; negotiation with insurers regarding coverages, costs, and payment options; implementation of retained and transferred risk programs; monitoring of annual program; and insurance audit services.    (Code 1981, §33-23-1.1, enacted by Ga. L. 1993, p. 778, § 1; Ga. L. 2001, p. 925, § 1.)
GA Code § 33-23-2 (2021)
2021 Georgia Code|Title 33 - Insurance|Chapter 23 - Licensing|Article 1 - Agents, Agencies, Subagents, Counselors, and Adjusters|§ 33-23-2. Licenses to Be Issued Only to Individuals

 Reserved. Repealed by Ga. L. 2001, p. 925, § 1, effective July 1, 2002.   Editor's notes.   - This Code section was based on Ga. L. 1992, p. 2830, § 1; Ga. L. 1999, p. 878, § 3.