Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-29 - RULES AND REGULATIONS FOR HEALTH MAINTENANCE ORGANIZATIONS › Rule 111-8-29-.02 - Definitions

Current through Rules and Regulations filed through June 27, 2024
Unless a different meaning is required or given in the
				  context, the following terms as used in these rules and regulations shall have
				  the meaning hereinafter respectively ascribed to them:
(a) "Basic Health Care Services" means
				healthcare services which an enrolled population might reasonably require in
				order to be maintained in good health, including as a minimum but not
				restricted to, preventive care, emergency care, inpatient hospital and
				physician care, and outpatient medical services;
(b) "Commissioner" means the Commissioner of
				the Georgia Department of Community Health or his designee;
(c) "Complaint" means a written expression of
				concern by an enrollee or provider regarding the provision of health care
				services by the HMO or a condition in the operation of an HMO which affects an
				enrollee or provider to such an extent as to be viewed by such as deserving of
				formal redress;
(d) "Department"
				means the Georgia Department of Community Health (DCH);
(e) "Enrollee" means an individual person who
				is enrolled in a health benefits plan;
(f) "Governing Body" means the person or
				persons, natural or corporate, in which the ultimate responsibility, authority
				and accountability for the conduct of the HMO is vested;
(g) "Health Benefits Plan" means any
				arrangement whereby any person undertakes to provide, arrange for, pay for, or
				reimburse any part of the cost of any health care services and at least part of
				such arrangement consists of arranging for or the provision of health care
				services, as distinguished from an arrangement which provides only for
				indemnification against the cost of such services, on a prepaid basis through
				insurance or otherwise;
(h) "Health
				Care Services" means any services included in the furnishing to any individual
				of medical or dental care, or hospitalization or incident to the furnishing of
				such care or hospitalization, as well as the furnishing to any person of any
				and all other services for the purpose of preventing, alleviating, curing, or
				healing human illness or injury;
(i) "Health Education" means the provision of
				health information and the use of educational techniques to modify an
				individual's or family's knowledge and/or behavior to achieve and maintain
				optimum physical and mental health and to prevent illness, injury, chronicity,
				or unnecessary disability;
(j)
				"Health Maintenance Organization" or "HMO" means any legal entity subject to
				the provisions of the Georgia Health Maintenance Organization Act;
(k) "Health Professional" means those
				professionals engaged in the delivery of health services who are currently
				licensed to practice in the State of Georgia, or provide services authorized
				under an institutional license, or are certified, or practice under authority
				consistent with Georgia laws;
(l)
				"In-Area" means the geographical area defined by the health maintenance
				organization as its service area in which it provides health services to its
				enrollees directly through its own resources or through arrangements with other
				providers in the area;
(m)
				"Insurance Commissioner" means the Insurance Commissioner of the State of
				Georgia or his designee;
(n)
				"Medical Audit" means the retrospective examination and evaluation of the
				documentation of clinical application of medical knowledge as revealed
				inpatient health records for the purposes of education, accountability, and
				quality assurance;
(o)
				"Out-of-Area" means that area outside of the geographical area defined by the
				health maintenance organization as its service area;
(p) "Physician" means an individual who is
				currently licensed to practice medicine, surgery, or osteopathy in the State of
				Georgia, under the Georgia Medical Practice Act, Chapter 84-9, Georgia Laws
				Ann.;
(q) "Primary Care Physician"
				means the physician responsible for the management of medical care and
				coordination of health care services of an enrollee;
(r) "Provider" means any physician, hospital,
				or other person or facility which is licensed or otherwise authorized in this
				State to furnish health care services;
(s) "Peer Review" means professional
				evaluation by currently licensed professional persons in the same category as
				those being reviewed, of the performance of individuals in the medical and
				related health care fields for the purpose of achieving and maintaining high
				standards of care and professional practice;
(t) "Person" means any individual,
				institution, partnership, association, corporation, the State, or any
				municipalities or subdivision thereof, or any other entity whether organized
				for profit or not;
(u) "Quality
				Assurance Program" means the planned systematic medical and/or management
				actions which assure consistent rendering of high quality health care services
				through the use of monitoring and evaluation techniques;
(v) "Service Area" means the defined
				geographical area (i.e., boundaries of political subdivisions, census tracts,
				Area Planning and Development Commissions or Health System's Agencies, etc.) in
				which HMO services are available and readily accessible to enrollees;
(w) "Subscriber" means an enrollee who has
				entered into a contractual relationship for the provision of/or arrangement of
				health care services from an HMO for himself and/or his dependents;
(x) "Supplemental Health Services" means
				those health services offered in addition to "Basic Health Care
				Services."
Ga. L. 1964,
				  pp. 499, 507, 523; Ga. L. 1979, p. 1148
et seq
.; O.C.G.A.
				  §
											33-21-1
et
				  seq
.