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 120-2-111 - PATIENT'S RIGHT TO INDEPENDENT REVIEW › Rule 120-2-111-.03 - Standards

Current through Rules and Regulations filed through June 27, 2024
(1) Certification
				of Independent Review Organizations.
(a)
				Filing Information. An application for certification of an independent review
				organization and certification fee must be filed with the Department of
				Insurance, Administrative Procedure Division, electronically at the following
				email address: adminprocedure@oci.ga.gov. There shall be a fee for the
				application to become an independent review organization, and to renew the
				certification as an independent review organization, and the provisions
				governing such fees shall be as follows:
The Department shall establish, administer, and enforce the
				  certification and renewal fees under this section, and the fee for initial
				  application to receive certification as an independent review organization
				  shall be $500; and the fee for annual certification renewal as an independent
				  review organization shall be $250.00.
(b) How to Obtain Forms. The application must
				be submitted on a form which can be obtained from the Department of Insurance,
				Administrative Procedure Division at adminprocedure@oci.ga.gov.
(c) Certification Application Content. The
				applicant must provide information required by the Department, which includes,
				but is not limited to the following:
1. A
				summary of the independent review plan which meets the requirements of this
				Rule as outlined below and must include:
(i)
				the screening criteria and review procedures to be used to determine medical
				necessity, medically necessary care, or medically necessary and appropriate
				care;
(ii) a certification signed
				by an authorized representative that such screening criteria and review
				procedures to be applied in review determinations are established with input
				from appropriate health care providers, including physicians;
(iii) procedures ensuring that the
				information regarding the reviewing physicians and providers is updated in
				accordance with this Rule as outlined below relating to Revisions During Review
				Process and relating to Renewal of Certificate of Registration to ensure the
				independence of each health care provider or physician making review
				determinations; and
(iv) specific
				procedures which will be used to determine if a proposed treatment is
				experimental.
2. Copies
				of policies and procedures which ensure that all applicable state and federal
				laws to protect the confidentiality of medical records and personal information
				are followed. These procedures must comply with this Rule as outlined below
				relating to Confidentiality; and the applicant shall also submit a
				certification signed by an authorized representative that the independent
				review organization will protect the confidentiality of medical records and
				personnel information and will comply with all applicable state and federal
				laws pertaining thereto.
3. A
				certification signed by an authorized representative that the independent
				review organization will comply with the provisions of the Act and these
				Rules;
4. A description of
				personnel and the accrediting policies and procedures of the applicant, and a
				completed profile for each expert reviewer and provider, in compliance with
				this Rule as outlined below relating to Personnel and Credentialing;
5. A description of hours of operation, which
				must conform to Eastern Standard Time or Eastern Daylight Time, whichever is
				applicable, and how the independent review organization may be contacted during
				weekends and holidays, as set forth in this Rule as outlined below relating to
				Independent Review Organization's Telephone Access;
6. The organizational information, documents
				and all amendments, including:
(i) The bylaws,
				Rules and regulations, or operating agreement regulating the conduct of the
				internal affairs of the applicant with a notarized certification bearing the
				original signature of an officer or authorized representative of the applicant
				that they are true, accurate, and complete copies of the originals;
(ii) For an applicant that is publicly held,
				the name of each stockholder or owner of more than five percent of any stock or
				options;
(iii) A chart listing the
				internal organizational structure of the applicant's management and
				administrative staff;
(iv) A chart
				showing contractual arrangements of the independent review system;
				and
(v) Evidence of the applicant's
				authorization to conduct business in the state of Georgia.
7. The name of any holder of bonds or notes
				of the applicant that exceed $ 100,000;
8. The name and type of business of each
				corporation or other organization that the applicant controls or is affiliated
				with and the nature and extent of the affiliation or control and a chart or
				list clearly identifying the relationships between the applicant and any
				affiliates;
9. Biographical
				information about officers, directors, and staff, including:
(i) The independent review organization must
				submit the name and biographical information for each director, officer, and
				executive of the applicant, any entity listed in this section of these Rules,
				and each expert reviewer conducting independent review, and a description of
				any relationship, including but not limited to, any past, present or known
				future professional, personal, familial, financial, fiduciary, or contractual
				relationship which the named individual has with:
(I) A health benefit plan;
(II) A health maintenance
				organization;
(III) An
				insurer;
(IV) A nonprofit health
				corporation;
(V) A payor;
(VI) A health care provider; or
(VII) A group representing any of the
				entities described by paragraphs (aa) through (gg) of this
				subsection;
(ii) Any
				relationship between the independent review organization and any affiliate or
				other organization in which a shareholder has 10 percent (10%) or more interest
				must be clearly identified;
(iii) A
				list of any currently outstanding loans or contracts to provide services
				between the applicant and any of its affiliates or any officers of its
				affiliates;
10.
				Information related to out-of-state licensure, permit, certification or other
				similar business, and service of legal process. All applicants must furnish a
				copy of the certificate of registration, licensing, or other similar document
				from the domiciliary state's licensing authority. As a condition of being
				certified to conduct the business of independent review in this state, an
				independent review organization that maintains its principal offices or any
				portion of its books, records, or accounts outside this state must appoint and
				maintain a person in this state as attorney for service of process on whom all
				judicial and administrative process, notices, or demands may be served, and
				must notify the Department of any change of appointment or appointee's address
				immediately.
11. Written disclosure
				of types of compensation arrangements made to physicians and providers in
				exchange for the provision of independent review, including any financial
				incentives for physicians and providers.
12. The percentage of the applicant's
				revenues that are anticipated to be derived from independent reviews
				conducted.
13. The names of any
				predecessor affiliates and/or companies, including trade names.