reglab/statecodes huggingface dataset:
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-34 - Representatives for enrollee; cost of review; cooperation

(a)
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.
(b)
A managed care entity shall be required to pay the full cost of applying for and obtaining the independent review.
(c)
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.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-35 - Request for independent review

(a)
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.
(b)
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.
(c)
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.
(d)
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.
(e)
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.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-36 - Additional information required for independent review

(a)
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:
(1)
Any information submitted to the managed care entity by the eligible enrollee in support of the eligible enrollee's grievance procedure filing;
(2)
A copy of the contract provisions or evidence of coverage of the managed care plan; and
(3)
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.
(b)
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.
(c)
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.
(d)
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.
(e)
The independent review organization's decision shall be based upon a review of the information and documentation submitted to it.
(f)
Information required or authorized to be provided pursuant to this Code section may be provided by facsimile transmission or other electronic transmission.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-37 - Effect of favorable determinations

(a)
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.
(b)
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.
(c)
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.
Amended by 2011 Ga. Laws 52,§; 46, eff. 1/1/2013.
Added by 2005 Ga. Laws 399,§; 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 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.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-40 - Determining medical necessity or whether a treatment is experimental

(a)
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
.
(b)
For the purposes of this article, in making a determination as to whether a treatment is experimental, the expert reviewer shall determine:
(1)
Whether such treatment has been approved by the federal Food and Drug Administration; or
(2)
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.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 33-20A-41 - Rules and regulations

The department shall provide necessary rules and regulations for the implementation and operation of this article.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 2 - PATIENT'S RIGHT TO INDEPENDENT REVIEW (§§ 33-20A-30 — 33-20A-42) › Section 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.
Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 3 - PAYMENT OF CLAIMS (§§ 33-20A-60 — 33-20A-62) › Section 33-20A-60 - Definitions

As used in this article, the term:
(1)
"Agent" shall not include an agent or agency as defined in Code Section
33-23-1
.
(2)
"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.
(3)
"Claimant" means any provider, facility, or individual making a claim under a health benefit plan on behalf of an enrollee.
(4)
"Enrollee" has the same meaning as provided in Code Section
33-20A-3
.
(5)
"Health benefit plan" has the same meaning as provided in Code Section
33-24-59.5
.
(6)
"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.
(7)
"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.
(8)
"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.
Amended by 2019 Ga. Laws 139,§ 1-90, eff. 7/1/2019.
Amended by 2003 Ga. Laws 9, § 33, eff. 5/14/2003.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20A - MANAGED HEALTH CARE PLANS (§§ 33-20A-1 — 33-20A-70) › Article 4 - JOINT COMMITTEE TO STUDY PRESCRIPTION COSTS IN STATE FUNDED HEALTH CARE PLANS (§ 33-20A-70) › Section 33-20A-70 - [Repealed] Creation; members; meetings; duties; cooperation by the Department of Community Health; members' expenses; repealer

Added by 2005 Ga. Laws 399,§ 1, eff. 5/10/2005.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-1 - Short title

This chapter shall be known and may be cited as the "Essential Rural Health Care Provider Access Act."
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-2 - Definitions

As used in this chapter, the term:
(1)
"Essential rural health care provider" means any hospital, federally qualified health center, or rural health clinic, as such terms are defined in this Code section, which is located in a rural area and which complies with the provisions of Code Section
33-20B-3
.
(2)
"Federally qualified health center" means, for the purposes of this Code section, a facility which meets the definition of a federally qualified health center as described in Section 1395x(aa)(4) of Title 42 of the United States Code Annotated and which is located in a rural area.
(3)
"Health benefit plan" or "plan" means the health insurance policy or subscriber agreement between a covered person or policyholder and a health care insurer which defines the covered services and benefit levels available.
(4)
"Health care insurer" means an insurer, a fraternal benefit society, a health care plan, a health care corporation, a health maintenance organization, or any other entity authorized to sell accident and sickness insurance policies, subscriber certificates, or other contracts of health insurance by whatever name called under this title.
(5)
"Health care services" means services rendered or products sold by an essential rural health care provider within the scope of such provider's license or legal authorization.
(6)
"Hospital" means any building or facility licensed by the Department of Community Health as a hospital under this chapter which:
(A)
Operates no more than 100 beds;
(B)
Provides 24 hour emergency care as well as a range of health care services sufficient to support the practice of a primary care physician; and
(C)
For at least one of the immediately preceding two fiscal years, derived at least 40 percent of its patient revenues from medicare, Medicaid, or any combination of medicare and Medicaid.
(7)
"Physician" for purposes of this Code section only means any person who is licensed to practice medicine by the Georgia Composite Medical Board pursuant to Chapter 34 of Title 43 who practices as a family physician, general internist, pediatrician, general practitioner, general surgeon, or obstetrician/gynecologist and who has medical staff privileges at a hospital as defined in paragraph (6) of this Code section.
(8)
"Rural area" means any county having a population of less than 35,000 according to the United States decennial census of 1990 or any future such census.
(9)
"Rural health clinic" means a facility which is located in a rural area and which meets the definition of a rural health clinic as described in Section 1395x(aa)(2) of Title 42 of the United States Code Annotated.
Amended by 2020 Ga. Laws 521,§ 33, eff. 7/29/2020.
Amended by 2019 Ga. Laws 139,§ 1-91, eff. 7/1/2019.
Amended by 2017 Ga. Laws 52,§ 10, eff. 7/1/2017.
Amended by 2009 Ga. Laws 243,§ 2, eff. 7/1/2009.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-3 - Qualifications for participating providers; reasonable consideration

(a)
Any essential rural health care provider shall have the opportunity to become a participating provider of health care services in a health benefit plan if such provider meets all of the following conditions:
(1)
Participates in the medicare and Medicaid programs;
(2)
Adopts and complies with a policy for the provision of health care services to indigent and charity patients;
(3)
Is licensed, where required under law, and qualified to render the services provided by the plan;
(4)
Agrees to payment terms which are either:
(A)
The same payment terms applicable to other similar participating providers in the plan; or
(B)
Such payment terms as may be mutually agreed upon by such provider and a health care insurer; and
(5)
Meets the reasonable and nondiscriminatory qualifications and standards established by the plan. Plan standards must comply with all applicable laws and regulations, but such qualifications and standards may not discriminate against essential rural health care providers on the basis of geographic proximity to other participating providers or corporate status.
(b)
All essential rural health care providers within a defined service area who meet the conditions established in subsection (a) of this Code section shall be given the opportunity to apply to become a participating provider in a plan. Provisions within a health benefit plan applicable to providers in such plan shall be applied by the health care insurer in a uniform and consistent manner to similarly situated providers. In the event an essential rural health care provider requests the opportunity to become a participating provider in any health benefit plan, the health care insurer shall conduct reasonable and good faith negotiations with such essential rural health care provider to determine whether it meets the applicable qualifications and standards established by the plan in accordance with all applicable laws, rules, and regulations as promulgated by the Commissioner of Insurance.
(c)
Health benefit plans shall include sufficient and reasonable numbers of physicians located in rural areas.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-3.1 - Health maintenance organizations' expansion into rural areas

When reviewing a health maintenance organization's request to originate or expand an area of service into a rural area, the commissioner of community health shall consider whether the health maintenance organization has demonstrated its willingness to grant reasonable consideration to essential rural health care providers in the negotiating and contracting process.
Amended by 2009 Ga. Laws 102,§ 1-6, eff. 7/1/2009.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-4 - Termination as a participating provider

To deny, reject, or terminate an essential rural health care provider from serving as a participating provider in a health benefit plan, the health care insurer shall:
(1)
Inform the essential rural health care provider in writing of the basis for such rejection or termination, including a reference to any specific qualification or standard established by the plan in accordance with all applicable laws and regulations which the provider failed to meet; and
(2)
Where possible, afford the essential rural health care provider a reasonable opportunity to cure the deficiency which is the basis for such rejection or termination.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20B - ESSENTIAL RURAL HEALTH CARE PROVIDER ACCESS (§§ 33-20B-1 — 33-20B-6) › Section 33-20B-5 - Hearing and appeal rights of denied providers

Any essential rural health care provider which is denied, rejected, or terminated from serving as a participating provider in a health benefit plan shall have the right of hearing and appeal before the Commissioner, or his or her designee, if that provider believes there has been a violation of this chapter and of judicial appeal as provided in Chapter 2 of this title. To the extent proprietary materials, trade secrets, rate data, or other materials not generally known to the public are presented at a hearing or an appeal, such information shall be admissible but shall be sealed by the Commissioner and held as confidential and shall not be subject to Article 4 of Chapter 18 of Title 50.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20C - HEALTH CARE NETWORK PROVIDER INFORMATION (§§ 33-20C-1 — 33-20C-7) › Section 33-20C-4 - Information and searchable format for directories; exclusion for dental plans

(a)
The insurer shall make available through an online provider directory, for each network plan, the following information, in a searchable format:
(1)
For healthcare professionals:
(A)
Name;
(B)
Gender;
(C)
Contact information;
(D)
Participating office location or locations;
(E)
Specialty, if applicable;
(F)
Board certifications, if applicable;
(G)
Medical group affiliations, if applicable;
(H)
Participating facility affiliations, if applicable;
(I)
Languages spoken other than English by the healthcare professional or clinical staff, if applicable;
(J)
Tier; and
(K)
Whether they are accepting new patients;
(2)
For hospitals:
(A)
Hospital name;
(B)
Hospital type, such as acute, rehabilitation, children's, or cancer;
(C)
Participating hospital location;
(D)
Hospital accreditation status;
(E)
Telephone number; and
(F)
Health benefit plan surprise bill rating; and
(3)
For facilities other than hospitals:
(A)
Facility name;
(B)
Facility type;
(C)
Types of services performed;
(D)
Participating facility location or locations; and
(E)
Telephone number.
(b)
Paragraphs (2) and (3) of subsection (a) of this Code section shall not apply to standalone dental plans.
Amended by 2020 Ga. Laws 475,§ 2, eff. 11/1/2020.
Added by 2016 Ga. Laws 341,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20C - HEALTH CARE NETWORK PROVIDER INFORMATION (§§ 33-20C-1 — 33-20C-7) › Section 33-20C-5 - Printed directories; accuracy; application to standalone dental plans

(a)
The insurer shall make available in print, upon request, the following provider directory information for the applicable network plan:
(1)
For healthcare professionals:
(A)
Name;
(B)
Contact information;
(C)
Participating office location or locations;
(D)
Specialty, if applicable;
(E)
Languages spoken other than English, if applicable; and
(F)
Whether accepting new patients;
(2)
For hospitals:
(A)
Hospital name;
(B)
Hospital type, such as acute, rehabilitation, children's, or cancer;
(C)
Participating hospital location and telephone number; and
(D)
Health benefit plan surprise bill rating; and
(3)
For facilities other than hospitals:
(A)
Facility name;
(B)
Facility type;
(C)
Types of services performed; and
(D)
Participating facility location or locations and telephone number.
(b)
The insurer shall include a disclosure in the print directory that the information in subsection (a) of this Code section and included in the directory is accurate as of the date of printing and that covered persons or prospective covered persons should consult the insurer's electronic provider directory on its website or call a specified customer service telephone number to obtain current provider directory information.
(c)
Paragraphs (2) and (3) of subsection (a) of this Code section shall not apply to standalone dental plans.
Amended by 2020 Ga. Laws 475,§ 3, eff. 11/1/2020.
Amended by 2017 Ga. Laws 251,§ 1, eff. 7/1/2017.
Added by 2016 Ga. Laws 341,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20C - HEALTH CARE NETWORK PROVIDER INFORMATION (§§ 33-20C-1 — 33-20C-7) › Section 33-20C-6 - Exclusion for services provided through Department of Community Health

This chapter shall not apply to the provision of health care services pursuant to a contract entered into by an insurer and the Department of Community Health for recipients of Medicaid or PeachCare for Kids and the state health benefit plan under Article 1 of Chapter 18 of Title 45.
Added by 2016 Ga. Laws 341,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20C - HEALTH CARE NETWORK PROVIDER INFORMATION (§§ 33-20C-1 — 33-20C-7) › Section 33-20C-7 - Disclosure of health benefit plan surprise bill rating in advertisement; other disclosures; regulation; optional annual reporting

(a)
Each insurer that advertises or designates any hospital as in-network shall be required to disclose the relevant health benefit plan surprise bill rating within such advertisement, notwithstanding the type or form of such advertisement.
(b)
If a health benefit plan surprise bill rating is less than four checkmarks, each insurer advertising a hospital as in-network shall describe which qualified hospital based specialty group types are not contracted with such health benefit plan.
(c)
The Commissioner may promulgate rules and regulations which require insurers to provide explanatory footnotes to each health benefit plan surprise bill rating in such special circumstances as the Commissioner may determine to be appropriate.
(d)
If an insurer processes a claim on a covered person from an out-of-network qualified hospital based specialty group provider at out-of-network rates, such insurer shall update the relevant health benefit plan surprise bill rating within 30 days to reflect any necessary reduction in such rating.
(e)
The Commissioner may submit an annual report to the House Committee on Insurance and the Senate Insurance and Labor Committee beginning January 1, 2022. Such report may include such aggregate data as the Commissioner determines beneficial to share with such committees.
Added by 2020 Ga. Laws 475,§ 4, eff. 11/1/2020.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20D - RENTAL PREFERRED PROVIDER NETWORKS (§§ 33-20D-1 — 33-20D-6) › Section 33-20D-1 - Definitions

As used in this chapter, the term:
(1)
"Affiliate" means an entity owned or controlled, either directly or through a parent or subsidiary entity, by a contracting entity that accesses the rates, terms, or conditions of health care services.
(2)
"Contracting entity" means any person or entity that enters into direct contracts with health care providers for the delivery of health care services in the ordinary course of business, including a health care organization or hospital organization when leasing or renting the health care organization's or hospital organization's network to a third party.
(3)
"Covered person" means an individual who is covered under a health insurance plan.
(4)
"Health care services" means the examination or treatment of persons for the prevention of illness or the correction or treatment of any physical or mental condition resulting from illness, injury, or other human physical problem.
(5)
"Health insurer" means an accident and sickness insurer, health care corporation, health maintenance organization, provider sponsored health care corporation, or any similar entity regulated by the Commissioner.
(6)
"Provider network contract" means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of and payment for health care services to covered persons.
(7)
"Rental preferred provider network" means a preferred provider network that contracts with a health insurer or other payor or with another preferred provider network to grant access to the terms and conditions of its contract with providers of health care services. Such contracts are often referred to as "renting" or "leasing" the network. The term "rental preferred provider network" does not refer to a proprietary network of a licensed insurer or to arrangements providing for access to the proprietary network of a licensed insurer by affiliates of the licensed insurer or by entities receiving administrative services from the licensed insurer or its affiliates.
(8)
"Third party" means an organization that enters into a contract with a contracting entity or with another third party to gain access to a provider network contract.
Added by 2016 Ga. Laws 407,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20D - RENTAL PREFERRED PROVIDER NETWORKS (§§ 33-20D-1 — 33-20D-6) › Section 33-20D-2 - Registration with Commissioner; requirements; fee; approved list

(a)
Any person who commences business as a rental preferred provider network shall register with the Commissioner within 30 days of commencing business in this state unless such person is licensed by the Commissioner as a health insurer. Each rental preferred provider network not licensed by the Commissioner on July 1, 2016, shall be required to register with the Commissioner no later than September 30, 2016, and shall be placed on an approved list maintained by the Commissioner.
(b)
Registration shall consist of the submission of the following information:
(1)
The official name of the rental preferred provider network, including any d/b/a designations used in this state;
(2)
The mailing address and main telephone number for the rental preferred provider network's main headquarters; and
(3)
The name and telephone number of the rental preferred provider network representative who shall serve as the primary contact with the department.
(c)
The information required by this Code section shall be submitted in written or electronic format, as prescribed by the Commissioner by rule or regulation.
(d)
The Commissioner may, pursuant to rule or regulation, collect a reasonable fee for the purpose of administering the registration process.
(e)
The Commissioner shall maintain an approved list of rental preferred provider networks.
Added by 2016 Ga. Laws 407,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20D - RENTAL PREFERRED PROVIDER NETWORKS (§§ 33-20D-1 — 33-20D-6) › Section 33-20D-4 - Rights and responsibilities imposed on third parties

(a)
A third party, having itself been granted access to a network provider's health care services and contractual discounts pursuant to a provider network contract, that subsequently grants access to another third party shall be obligated to comply with the rights and responsibilities imposed on contracting entities pursuant to this chapter.
(b)
A third party that enters into a contract with another third party to access a network provider's health care services and contractual discounts pursuant to a provider network contract shall be obligated to comply with the rights and responsibilities imposed on third parties under this Code section.
Added by 2016 Ga. Laws 407,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20D - RENTAL PREFERRED PROVIDER NETWORKS (§§ 33-20D-1 — 33-20D-6) › Section 33-20D-5 - Exclusions

This chapter shall not apply to:
(1)
Provider network contracts for services provided to Medicaid, medicare, the state health benefit plan under Article 1 of Chapter 18 of Title 45, or State Children's Health Insurance Program (SCHIP) beneficiaries;
(2)
Employers, church plans, or government plans receiving administrative services from a rental preferred provider network or its affiliates, or pharmacy benefits managers;
(3)
Circumstances where access to the provider network contract is granted to an entity operating under the same brand licensee program as the contracting entity;
(4)
The provision of any medical services for injuries covered under Chapter 9 of Title 34, relating to workers' compensation; or
(5)
Self-funded, employer sponsored health insurance plans regulated under the Employee Retirement Income Security Act of 1974, as codified and amended at
29 U.S.C. Section 1001
, et seq.
Added by 2016 Ga. Laws 407,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20D - RENTAL PREFERRED PROVIDER NETWORKS (§§ 33-20D-1 — 33-20D-6) › Section 33-20D-6 - Penalties

Any person or entity that is not duly licensed or that should be licensed by the department or that is not duly registered or that should be registered with the department pursuant to Code Section
33-20D-2
and acts as a rental preferred provider network, as defined in paragraph (7) of Code Section
33-20D-1
, shall be subject to penalties set forth in subsection (g) of Code Section
33-2-24
. The Commissioner shall have the authority, in addition to any other remedies and damages allowed by law, to seek to restrain or enjoin any person or entity, whether or not such person or entity is licensed or registered pursuant to this title, that is determined to be in violation of Code Section
33-20D-2
or
33-20D-3
, and such person or entity shall be liable for attorney fees and litigation expenses incurred in the action to restrain or enjoin such violation.
Added by 2016 Ga. Laws 407,§ 1, eff. 7/1/2016.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-1 - Short title

This chapter shall be known and may be cited as the "Surprise Billing Consumer Protection Act."
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-3 - Exemption

(a)
Nothing in this chapter shall be applicable to healthcare plans which are subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974,
29 U.S.C. Sec. 1001
, et seq.
(b)
This chapter shall be applicable only to healthcare plans and state healthcare plans as defined in this chapter.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-6 - Denying or restricting benefits based on balance billing; notice to insured

No healthcare plan shall deny or restrict the provision of covered benefits from a participating provider to a covered person solely because the covered person obtained treatment from a nonparticipating provider leading to a balance bill. Notice of such protection shall be provided in writing to the covered person by the insurer.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-7 - Surprise bill exclusion; requirements

(a)
Nothing in this chapter shall reduce a covered person's financial responsibilities in the event that such covered person chose to receive nonemergency medical services from an out-of-network provider. Such services shall not be considered a surprise bill for purposes of this chapter.
(b)
The covered person's choice described in subsection (a) of this Code section must:
(1)
Be documented through such covered person's written and oral consent in advance of the provision of such services; and
(2)
Occur only after such person has been provided with an estimate of the potential charges.
(c)
If during the provision of nonemergency medical services, a covered person requests that the attending provider refer such covered person to another provider for the immediate provision of additional nonemergency medical services, such referred provider shall be exempt from the requirements in subsection (b) of this Code section if the following requirements are satisfied:
(1)
The referring provider advises the covered person that the referred provider may be a nonparticipating provider and may charge higher fees than a participating provider;
(2)
The covered person orally and in writing acknowledges that he or she is aware that the referred provider may be a nonparticipating provider and may charge higher fees than a participating provider;
(3)
The written acknowledgment referenced in paragraph (2) of this subsection shall be on a document separate from other documents provided by the referring provider and shall include language to be determined by the Commissioner through rule and regulation; and
(4)
The referring provider records the satisfaction of the requirements in paragraphs (1), (2), and (3) of this subsection in the covered person's medical file.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-8 - Payer health claims data base; annual updating of website

(a)
Subject to appropriation, the department shall provide for the maintenance of an all-payer health claims data base and maintain records of insurer payments which shall track such payments by a wide variety of healthcare services and by geographic areas of this state. Such appropriation must specifically reference the Surprise Billing Consumer Protection Act. The department shall update information in the all-payer health claims data base on no less than an annual basis and shall maintain such information on the department's website.
(b)
In the event that the appropriation described in subsection (a) of this Code section is not made, the department shall update information from such other verifiable data as the Commissioner shall determine appropriate on no less than an annual basis and shall maintain such information on the department's website.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-9 - Arbitration of payment issues

(a)
If an out-of-network provider concludes that payment received from an insurer pursuant to Code Section
33-20E-4
or
33-20E-5
or if an out-of-network facility concludes that payment received from an insurer pursuant to Code Section
33-20E-4
is not sufficient given the complexity and circumstances of the services provided, the provider or facility may initiate a request for arbitration with the Commissioner. Such provider or facility shall submit such request within 60 days of receipt of such payment for the claim and concurrently provide the insurer with a copy of such request. Such payment shall be indicated by the insurer on the first page of the insurer's remittance to the out-of-network provider in a manner to be determined by the Commissioner through the promulgation of rules and regulations. Such rules and regulations shall specify when the time period to request arbitration commences.
(b)
A request for arbitration may involve a single patient and a single type of healthcare service, a single patient and multiple types of healthcare services, multiple patients and a single type of healthcare service, or multiple substantially similar healthcare services in the same specialty on multiple patients.
Amended by 2023 Ga. Laws 223,§ 3, eff. 7/1/2023.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-10 - Dismissal of arbitration requests

(a)
The Commissioner shall dismiss certain requests for arbitration if the disputed claim is:
(1)
Related to a healthcare plan that is not regulated by the state;
(2)
The basis for an action pending in state or federal court at the time of the request for arbitration;
(3)
Subject to a binding claims resolution process entered into prior to July 1, 2021;
(4)
Made against a healthcare plan subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974,
29 U.S.C. Sec. 1001
, et seq.; or
(5)
In accord with other circumstances as may be determined by department rule.
(b)
The Commissioner may dismiss certain requests for arbitration in the following circumstances:
(1)
The provider or facility has engaged in a pattern or practice of any of the following:
(A)
Failing to respond to the department's requests for data under Code Section
33-20E-11.1
;
(B)
Failing to respond to the department's other inquires after filing requests for arbitration; or
(C)
Failing to pay resolution organizations as required under Code Section
33-20E-16
;
(2)
The provider or facility failed to file its request for arbitration within 60 days of receipt of payment for the claim and concurrently provide the insurer with a copy of such request; or
(3)
The provider or facility failed to explain in detail the reasons arbitration is needed. Such explanation shall include a representation as to whether the insurer's payment was in accord with the relevant provisions of Code Sections
33-20E-4
or
33-20E-5
if the party requesting arbitration is an out-of-network provider, and Code Section
33-20E-4
if the requesting party is out-of-network facility. If such payment was in such accord, the explanation shall provide in detail the complexity and circumstances of the services provided which necessitate additional payment.
Amended by 2023 Ga. Laws 223,§ 4, eff. 7/1/2023.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-11 - Submission to Commissioner by insurer of data pending arbitration

Within 60 days of the insurer's receipt of the provider's or facility's request for arbitration, the insurer shall submit to the Commissioner all data necessary for the Commissioner to determine whether such insurer's payment to such provider or facility was in compliance with Code Section
33-20E-4
or
33-20E-5
. The Commissioner shall not be required to make such a determination prior to referring the dispute to a resolution organization for arbitration. When an insurer fails to submit such data within such 60 day period, the Commissioner may assess penalties against such insurer in accord with Code Section
33-2-24
or declare a default judgment against such insurer.
Amended by 2023 Ga. Laws 223,§ 5, eff. 7/1/2023.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-11.1 - Commissioner's authority to request data for arbitration; penalty

The Commissioner may request from a provider or facility requesting arbitration such data as the Commissioner deems necessary to determine whether the insurer's payment to such provider or facility was in compliance with Code Section
33-20E-4
or
33-20E-5
. The Commissioner shall not be required to make such determination prior to referring the dispute to a resolution organization for arbitration. If such provider or facility fails to submit such data within 60 days of such request, the Commissioner may fine such provider or facility up to $2,000.00 for each and every violation of the Commissioner's request for data or if such provider or facility knew or reasonably should have known that it was in violation of the Commissioner's request for data, the monetary penalty provided for in this Code section may be increased to an amount up to $5,000.00 for each and every act in violation.
Added by 2023 Ga. Laws 223,§ 6, eff. 7/1/2023.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-12 - Regulation; contracting with resolution organizations

The Commissioner shall promulgate rules implementing an arbitration process requiring the Commissioner to select one or more resolution organizations to arbitrate certain claim disputes between insurers and out-of-network providers or facilities. The Commissioner may promulgate such other rules as reasonably necessary to facilitate the arbitration process. Prior to proceeding with such arbitration, the Commissioner shall allow the parties 60 days from the date the Commissioner received the request for arbitration to negotiate a settlement. The parties shall timely notify the Commissioner of the result of such negotiation. If within 60 days of the date that the Commissioner received the request for arbitration, the parties have neither agreed upon a settlement nor agreed that more time is needed to negotiate a settlement, or both, or either party has failed to notify the Commissioner of such settlement or need for additional time to negotiate, the Commissioner shall within five days, refer the dispute to a resolution organization. The department shall contract with one or more resolution organizations by July 1, 2021, to review and consider claim disputes between insurers and out-of-network providers or facilities as such disputes are referred by the Commissioner.
Amended by 2023 Ga. Laws 223,§ 7, eff. 7/1/2023.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.
2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 20E - SURPRISE BILLING CONSUMER PROTECTION ACT (§§ 33-20E-1 — 33-20E-26) › Section 33-20E-13 - Selection of arbitrator

Upon the Commissioner's referral of a dispute to a resolution organization, the parties shall have five days to select an arbitrator by mutual agreement. If the parties have not notified the resolution organization of their mutual selection before the fifth day, the resolution organization shall select an arbitrator from among its members. Any selected arbitrator shall be independent of the parties and shall not have a personal, professional, or financial conflict with any party to the arbitration. The arbitrator shall have experience or knowledge in healthcare billing and reimbursement rates. He or she shall not communicate ex parte with either party.
Added by 2020 Ga. Laws 470,§ 1, eff. 1/1/2021.