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 120-2-106 - SURPRISE BILLING › Rule 120-2-106-.10 - Arbitration

Current through Rules and Regulations filed through June 27, 2024
(1) If an
				out-of-network provider concludes that payment received from an insurer
				pursuant to regulation
				120-2-106-.05 or
				120-2-106-.06 is not sufficient
				given the complexity and circumstances of the services provided. Or, if an
				out-of-network facility concludes that payment received from an insurer
				pursuant to Regulation
				120-2-106-.05 concludes the same,
				a request for arbitration with the Commissioner may be initiated. A request for
				arbitration must be submitted within 30 days of receipt of payment for the
				claim and concurrently provide the insurer with a copy of such
				request.
(2) All arbitration
				requests must be submitted to the Administrative Procedure Division of the
				Office of Insurance and Safety Fire Commissioner.
(3) Within 30 days of the insurer's receipt
				of a provider's or facility's request for arbitration, the insurer must submit
				to the Administrative Procedure Division all data necessary to determine
				whether the insurer's payment to such provider or facility complied with
				regulations
				120-2-106-.05 or
				120-2-106-.06.
(4) The Commissioner will dismiss specific
				arbitration requests if the disputed claim meets certain criteria laid out in
				O.C.G.A. §
									33-20E-10 or in Rule
				120-2-106-.08. Should an insurer
				believe one of these criteria is present, they should submit the appropriate
				data they believe supports this contention. Should the Commissioner dismiss a
				claim for meeting one of the criteria in O.C.G.A. §
									33-20E-10, the provider or
				facility may request a hearing under the rules contained in Regulation
				120-2-2.
(5) Before proceeding with
				arbitration, the parties will be permitted 30 days from the date the request
				was received to negotiate a settlement. The parties must notify the
				Administrative Procedure Division of the result of such negotiation. If the
				Administrative Procedure Division has not been notified within 30 days of the
				settlement negotiation's result, the claim will be sent to arbitration. The
				parties may still reach a negotiated settlement after the claim is referred but
				before arbitration begins. However, they will be responsible for splitting any
				costs incurred by the resolution organization due to the referral.
(6) Disputes are to be reviewed by
				independent resolution organizations with whom the Department will contract.
				The disputes will be decided pursuant to the rules as laid out in O.C.G.A.
				33-20E
et.
				seq.
(7) A list of the
				selected organizations and their approved fee schedules will be kept by the
				Administrative Procedure Division and available for review upon request. In
				contracting with each dispute resolution organization, the Department will
				ensure that appropriate safeguards are put in place so that information subject
				to trade secret protection laws is duly protected.
(8) Upon the Commissioner's referral of a
				dispute to a resolution organization, the parties will 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.
				Should the parties not agree to the resolution organization's choice of
				arbitrator, the Commissioner will select one for the parties; this decision
				will be final.
(9) Arbitrators
				should possess training and experience in health care billing, reimbursement,
				and usual and customary charges in consultation with a licensed doctor in
				active practice in the same or similar specialty as the doctor providing the
				service that is the subject of the dispute.
(10) In addition to the factors found in
				O.C.G.A. §
									33-20E-15, in deciding a claim,
				arbitrators should also consider the following factors:
(a) Whether there is a gross disparity
				between the fee charged by the provider and (1) fees paid to the provider for
				the same services provided to other patients in health care plans in which the
				provider is non-participating, and (2) the fees paid by the health plan to
				reimburse similarly qualified out-of-network providers for the same services in
				the same region;
(b) The provider's
				training, education, experience, and the usual charge for comparable services
				when the provider does not participate with the patient's health
				plan;
(c) In the case of a
				hospital, the teaching status, scope of services, and case-mix;
(d) The circumstances and complexity of the
				case;
(e) Patient characteristics;
				and
(f) For physician services, the
				usual and customary cost of the service.