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 120-2-58 - CERTIFICATION OF PRIVATE REVIEW AGENTS › Rule 120-2-58-.02 - Definitions

Current through Rules and Regulations filed through June 27, 2024
(1) "Active
				Practice" means activities including, but not limited to, the review of medical
				records and charts, participation in utilization review and medical management,
				evaluating medical necessity, monitoring patient therapy, graduate medical
				education, or maintenance of board certification.
(2) "Adverse Determination" means a
				determination based on medical necessity made by a private review agent or
				utilization review entity not to grant authorization to a hospital, surgical or
				other facility admission, extension of a hospital stay or other health care
				service or procedure based on medical necessity or appropriateness.
(3) "Appeal" means a formal request, either
				orally, or in writing or by electronic transmission, to a private review agent
				to reconsider a determination not to certify an admission, extension of stay,
				or other health care service or procedure.
(4) "Authorization" means a determination by
				a private review agent or utilization review entity that a healthcare service
				has been reviewed and, based on the information provided, satisfies the
				utilization review entity's requirements for medical necessity.
(5) "Claim Administrator" means any entity
				that reviews and determines whether to pay claims to covered persons on behalf
				of the healthcare plan. Such payment determinations are made on the basis of
				contract provisions including medical necessity and other factors. Claim
				administrators may be insurers or their designated review organization,
				self-insured employers, management firms, third-party administrators, or other
				private contractors.
(6) "Clinical
				Criteria" means the written policies, decisions, rules, medical protocols, or
				guidelines used by a private review agent or utilization review entity to
				determine medical necessity.
(7)
				"Clinical Peer" means a healthcare provider who is licensed without restriction
				or otherwise legally authorized and currently in active practice in the same or
				similar specialty as that of the treating provider, and who typically manages
				the medical condition or disease at issue and has knowledge of and experience
				providing the healthcare service or treatment under review.
(8) "Complaint" is a communication either
				orally, in writing or by electronic transmission concerning matters related to
				utilization review including, but not limited to, health care services,
				denials, accessibility, and confidentiality.
(9) "Concurrent Review" means utilization
				review conducted during a patient's hospital stay or course of
				treatment.
(10) "Covered Person"
				means an individual, including, but not limited to, any subscriber, enrollee,
				member, beneficiary, participant, or his or her dependent, eligible to receive
				healthcare benefits by a health insurer pursuant to a healthcare plan or other
				health insurance coverage.
(11)
				Emergency healthcare services means healthcare services rendered after the
				recent onset of a medical or traumatic condition, sickness, or injury
				exhibiting acute symptoms of sufficient severity, including, but not limited
				to, severe pain, that would lead a prudent layperson possessing an average
				knowledge of medicine and health to believe that his or her condition,
				sickness, or injury is of such a nature that failure to obtain immediate
				medical care could result in:
(A) Placing the
				patient's health in serious jeopardy;
(B) Serious impairment to bodily functions;
				or
(C) Serious dysfunction of any
				bodily organ or part.