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 120-2-80 - PATIENT PROTECTION ACT › Rule 120-2-80-.07 - Utilization Review

Current through Rules and Regulations filed through June 27, 2024
(1) All managed care entities offering
				managed care plans in this state shall have a utilization review program which
				complies with the requirements of Title 33, Chapter 46 and the Rules and
				Regulations of the Office of Commissioner of Insurance Chapter 120-2-58. Any
				managed care entity or contractor providing utilization review services for a
				managed care plan must be certified as a Private Review Agent in accordance
				with Chapter 120-2-58, or otherwise deemed compliant by the Commissioner only
				if such entity or contractor is an applicant that has been accredited by the
				Utilization Review Accreditation Commission and is operating as permitted by
				§
									120-2-58-.03(2).
(2) A managed care entity which conducts its
				own utilization review program, as part of its corporate structure or through
				another corporation owned and operated by the entity, for the purposes of
				utilization review of its managed care plans exclusively, must submit a
				separate application for certification as a Private Review Agent no later than
				six (6) months from the effective date of this Regulation Chapter to be deemed
				compliant. A managed care entity must notify the Commissioner in both its
				managed care plan certification application and its Private Review Agent
				application that it is conducting its own utilization review program, and must
				disclose in such notice the corporate arrangement under which such utilization
				review is occurring. All managed care entities are required to comply with
				state laws and Regulation Chapters regarding utilization review as of the
				effective date of this Regulation Chapter, and must obtain certification in
				order to continue providing utilization review services.
(3) A managed care entity which uses a
				managed care contractor or contractors for its utilization review program must
				notify the Commissioner in its managed care plan certification application of
				all such contractors for all its managed care plans, and the extent to which
				each contractor conducts utilization review. The managed care entity must
				attest that each contractor is either certified as a Private Review Agent or is
				deemed compliant as a Private Review Agent by the Commissioner.
(4) A managed care entity must submit
				materials which inform applicable insureds and providers of the requirements of
				the utilization review plan to the Commissioner. Such materials shall include,
				but are not limited to, certificates, policies, member handbook excerpts, and
				provider contract provisions. The description of the utilization review plan
				must be clear and comprehensive and include the rights and responsibilities of
				covered persons and providers. The ultimate responsibility for requesting
				certification of utilization of health care services must be described in
				accordance with the terms of coverage. The information must include
				requirements pertaining to emergency, urgent, or out-of-network services, if
				applicable.
(5) A managed care
				entity conducting utilization review as permitted in paragraph (2) must submit
				an application for certification as a Private Review Agent no later than the
				filing date for certification as a managed care plan under the Patient
				Protection Act. Such managed care entities shall be deemed to have a compliant
				utilization review program until such time as the Commissioner has made a
				formal determination on certification as a Private Review Agent.
O.C.G.A. Secs.
				  33-2-9,
				  33-20A-2,
				  33-20A-4,
				  33-20A-5,
				  33-46-2,
				  33-46-4.