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Subject 120-2-58 CERTIFICATION OF PRIVATE REVIEW AGENTS

Rule 120-2-58-.01 Purpose

The Purpose of this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance is to promote the delivery of quality health care by cost-effective means, efficient communication, protection of parties involved, accessible treatment done in a timely and effective manner, maintaining confidentiality of information, and to provide minimum standards for private review agents.

Rule 120-2-58-.02 Definitions

(1) "Adverse Determination" means a determination by a private review agent not to certify a hospital or surgical facility admission, extension of a hospital stay or other health care service or procedure based on medical necessity or appropriateness.
(2) "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.
(3) "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.
(4) "Concurrent Review" means utilization review conducted during a patient's hospital stay or course of treatment.
(5) "Reconsideration" means a request either orally, in writing or by electronic transmission to the private review agent to reconsider an adverse determination.
(6) "Review Criteria" means the written policies, decisions, rules, medical protocols or guidelines used by the private review agent to determine medical necessity or appropriateness.
(7) "Utilization Review Determination" means a recommendation by a private review agent regarding medical necessity or appropriateness of the health care services given or proposed to be given to a patient.

Rule 120-2-58-.03 Application and Renewal Filing Requirements

(1) Applications for certification shall be submitted to the Office of the Commissioner of Insurance on Forms GID-57, GID-65(UR) and GID-72, attached hereto and incorporated herein, along with the original license or certificate fee and application fee required for private review agents under O.C.G.A. 33-8-1.
(2) Private review agents operating in Georgia prior to the effective date of this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance and which have not applied for certification within sixty (60) days of such effective date shall be in violation of Chapter 46 of Title 33 of the Official Code of Georgia Annotated and this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance and are prohibited from operating as a private review agent until such private review agent has applied for certification and has been certified.
(3) Any private review agent not operating in Georgia on the effective date of this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance may apply for certification at any time prior to doing business in Georgia.
(4) A certificate shall expire on the second anniversary of its effective date unless renewed, suspended or revoked. Renewal for an additional two (2) year term may be applied for no sooner than ninety (90) days prior to the certification expiration date. Application for renewal shall be submitted on Forms GID-57, GID-65(UR) and GID-72 with the renewal license or certificate fee required for private review agents under O.C.G.A. § 33-8-1.
(5) On initial application for certification, all advertising materials to be used in Georgia by private review agents shall be filed with the Office of the Commissioner of Insurance.
(6) Each application for certification or renewal must include the following:
(a) A utilization review plan;
(b) Documentation that the private review agent has received full accreditation or certification by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). Reason or reasons should be stated if the organization is not presently fully accredited or certified by URAC or NCQA.
(c) The type, qualifications and number of the personnel, either employed or under contract, to perform the utilization review;
(d) A copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan;
(e) A written description of an ongoing quality assessment program;
(f) The written policies and procedures to ensure that an appropriate representative of the private review agent is reasonably accessible to patients and health care providers five (5) days a week during normal business hours in this State;
(g) The written policies and procedures to ensure that information obtained in the course of utilization review is maintained in a confidential manner. Such policies and procedures shall include, but not be limited to, the following:
1. Assurances that information obtained during the process of utilization review will be kept confidential in accordance with any applicable state or federal laws and regulations;
2. Assurances that the information collected for purposes of utilization review will be limited to the information necessary for the claims administrator to adjudicate the claim and used solely for the purposes of utilization review, quality management, discharge planning and case management;
3. Assurances that information obtained for purposes of utilization review will be shared only with those agents (such as the claims administrator) who have authority to receive such information;
4. Guidelines to prevent unauthorized release of individual enrollee information to the public. Information pertaining to the diagnosis, treatment or health of an enrollee shall be disclosed only to authorized persons. Release of information otherwise shall only be permitted with the express written consent of the covered enrollee, or pursuant to court order for the production of evidence or discovery, or as otherwise provided by state or federal law.
(h) The written policies and procedures establishing and maintaining a complaint system; and
(i) A sample John Doe copy of each type of contract or agreement to be executed between the private review agent and payor, employer, claim administrator, or other entity with certification that the private review agent shall not enter into any incentive payment provision contained in a contract or agreement with a payor which is based on reduction of services or the charges thereof, reduction of length of stay, or utilization or alternative treatment settings to reduce amounts of necessary or appropriate medical care.

Rule 120-2-58-.04 Refusal, Suspension and Revocation

The Office of Commissioner of Insurance may refuse to issue or renew and may suspend or revoke a certificate if a private review agent:

(a) Violates any provision or otherwise fails to comply with any provision of Chapter 46 of Title 33 of the Official Code of Georgia Annotated or this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance;
(b) Has intentionally misrepresented or concealed any material fact in any application for certification or on any form filed with the Commissioner of Insurance;
(c) Has obtained or attempted to obtain the certification by misrepresentation, concealment, or other fraud or uses a certification without proper authority; or
(d) Has failed to produce records in response to a written request by the Office of Commissioner of Insurance sent to the last known address of the private review agent.

Rule 120-2-58-.05 Requirements for Utilization Review

(1) Private review agents shall have sufficient staff to facilitate review in accordance with review criteria and shall designate one or more individuals able to effectively communicate medical and clinical information.
(2) Private review agent shall provide access to its review staff by a toll free or collect call telephone line during normal business hours. A private review agent shall have an established procedure to review timely call backs from health care providers and shall establish written procedures for receiving after-hour calls, either in person or by recording.
(3) Private review agent shall collect only the information necessary to certify the admission, procedure or treatment, length of stay, frequency and duration of services. All requests for information shall be made during normal business hours.
(4) Private review agents shall identify themselves prior to collecting necessary information.
(5) Private review agents shall establish and follow procedures and rules for on-site medical facility review.
(6) In the event a private review agent questions the medical necessity or appropriateness of care, the following procedures will apply:
(a) The attending health care provider shall have the opportunity to discuss a utilization review determination promptly by telephone with an identified health care provider representing the private review agent and trained in a related medical specialty. If the determination is made not to certify, an adverse determination exists.
(b) Reconsideration of an adverse determination occurs when any questions concerning medical necessity or appropriateness of care are not resolved under subparagraph (a) above. The right to appeal an adverse determination shall be available to the enrollee and the attending physician or other ordering health care provider. The enrollee or enrollee's representative shall be allowed a second review by another identified health care provider in an appropriate medical specialty who represents the private review agent.
(7) The private review agent shall have written procedures for providing notification of its determinations regarding all forms of certification in accordance with the following:
(a) When an initial determination is made to certify, notification shall be provided promptly either by telephone, in writing or electronic transmission to the attending health care provider, the facility rendering service as well as to the enrollee. Written notification shall be transmitted within two (2) business days of the determination.
(b) When a determination is made not to certify, the attending physician and/or other ordering health care provider or facility rendering service shall:
1. Be notified by telephone within one (1) business day.
2. Be sent a written notification within one (1) business day, which also shall be sent to the enrollee. The written notification shall include: principal reason(s) for the determination and instructions for initiating an appeal of the adverse determination.
(c) The private review agent shall establish procedures for appeals to be made in writing and by telephone. The private review agent shall notify the health care provider and enrollee in writing of its determination on the appeal as soon as possible, but in no case later than sixty (60) days after receiving the required documentation to conduct the appeal.
(d) The appeals procedure does not preclude the right of an enrollee to pursue legal action.

Rule 120-2-58-.06 Complaint Procedure

Private review agents shall establish and maintain a complaint system which includes, at a minimum, the following:

(a) All complaints shall be directed to the private review agent; and
(b) The private review agent shall contact the complainant, gather all pertinent facts regarding the complaint, and attempt to resolve the complaint as soon as reasonably possible within the context of written policies and procedures.

Rule 120-2-58-.07 Reporting Requirements

(1) By March 1, 1997, and annually thereafter on or before the same date, each private review agent shall submit to the Office of the Commissioner of Insurance a list of all complaints by type and disposition, and an analysis of such complaints files against them during the past calendar year.
(2) By March 1, 1997, and annually thereafter on or before the same date, the annual report information regarding utilization review activities for the preceding calendar year shall be submitted to the Office of Commissioner of Insurance on Form GID-73 which is attached hereto and incorporated herein.
(3) The Commissioner of Insurance shall require any other reporting requirements that are necessary to fully evaluate utilization review compliance with Chapter 46 of Title 33 of the Official Code of Georgia Annotated and this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance and the impact of utilization review programs on patient access to care.
(4) Each private review agent shall notify the Office of Commissioner of Insurance in writing within sixty (60) days of any changes to information last filed with the Office of Commissioner of Insurance under Form GID-57.

Rule 120-2-58-.08 Penalties

Any certified private review agent which violates or fails to comply with any provision of Chapter 46 of Title 33 of the Official Code of Georgia Annotated and this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance will be subject to fines and penalties applicable to licensed insurers generally, including revocation of its certification or right to do business in this state.

Rule 120-2-58-.09 Severability Provision

If any rule or portion of a rule in this Chapter of the Rules and Regulations of the Office of Commissioner of Insurance or the applicability thereof to any particular person or circumstance is held invalid by a court of competent jurisdiction, the remainder of the rules or the applicability of such provisions to other persons or circumstances shall not be affected thereby.

JOHN W. OXENDINE

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

APPLICATION FOR CERTIFICATION AS A PRIVATE REVIEW AGENT

(Typewritten Only)

If you are an individual with a disability and wish to acquire this application in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031

Application is hereby made for certification to operate as a Private Review Agent pursuant to the Laws of Georgia. In support thereof, the following information and documentary evidence is submitted:

Date of filing:____________________________________________

Name of organization:______________________________________

Mailing address:___________________________________________

Street address:____________________________________________

Office building:_________________________ Room number:______

City:____________________________ County:___________________

State:_____________________________ Zip:____________________

Telephone number: (___)__________Fax number: (___)_________

Name of Attorney or Principal filing this application:

___________________________________________________________

Mailing address:___________________________________________

Street address:____________________________________________

City:__________________________ State:______________________

Zip:_______________________

Telephone number: (___)__________Fax number: (___)_________

NOTE: ANSWER THE FOLLOWING QUESTIONS AND PROVIDE THE INFORMATION REQUESTED ON SEPARATE SHEETS IDENTIFYING EACH BY THE CORRESPONDING NUMBER ON THIS APPLICATION.

1. Submit all applicable organizational documents including an organizational chart. The following documents MUST BE an original copy or a certified copyof the original: partnership agreement; articles of incorporation certified by your Secretary of State; trade name certificate; trust agreement; any other applicable documents; and all amendments to those documents.

2. Provide one copy of the bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal.

3. List the names, addresses, and official titles of positions held by individuals who are responsible for the conduct of the affairs of the private review agent in Georgia.

4. Submit one copy of the Biographical Affidavit on Form GID-65(UR) for each of the persons listed in item 3.

5. Indicate if the private review agent plans to utilize a fictitious or "dba" name. If so, attach a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business.

6. Submit all other items required under Rule 120-2-58-.03(6).

DIRECTIONS FOR ATTESTING TO THIS APPLICATION:

a. If applicant is a sole proprietor, the application must be sworn by the sole proprietor.

b. If applicant is a partnership, the application must be sworn by the principal partners or by all officers and directors.

c. If applicant is a corporation, the application must be sworn by the president and secretary.

==============================================================

THE FOLLOWING ATTESTATION FORM SHALL BE USED:

I do solemnly swear or affirm that I am familiar with the Laws of Georgia relating to Private Review Agents; that I have complied with all of the requirements of O.C.G.A. §§ 33-46-4, 33-46-5 and Chapter 39 of Title 33 of the Official Code of Georgia Annotated; that all the foregoinginformation and documentary evidence submitted is true,complete, and correct to the best of my knowledge and belief. I understand that my certification is subject to administrative action if false information is contained herein.

_________________________

Organization

_________________________

Signature of Affiant

_________________________

Name (typewritten)

_________________________

Title (typewritten)

Sworn to and subscribed before me this_________ day of________,19_______.

_____________________________________

(Notary Public)

JOHN W. OXENDINE

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

Biographical Affidavit

(Typewritten Only)

If you are an individual with a disability and wish to acquire this affidavit in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031.

Full Name and Address of Private Review Agent (Do Not Use Group Names).

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

In connection with the above-named private review agent, I herewith make representations and supply information about myself as herein-after set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS "NO" or "NONE", SO STATE.

1. Affiant's Full Name (Initials Not Acceptable)._________

_______________________________________________________

_______________________________________________________

2.

a. Have you ever had your name changed? - If yes, give the reason for the change.____________________

___________________________________________________

___________________________________________________

___________________________________________________

b. Other names used at any time

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

3. Affiant's Business Address_____________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

4. Present or Proposed Position with the Applicant Organization

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

5. Present employer may be contacted.

Yes No (Circle One)

6. List any professional licenses issued by any public or governmental licensing agency or regulatory authority which you presently hold or have held in the last ten (10) years (state date license issued, issuer of license, date terminated, reasons for termination).

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

7. Has the certificate of authority or license to do business of any private review agent of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position?

____________________If yes, give details:

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Dated and signed this______________ day of________________ at _____________________.I hereby certify under penalty of perjury that I am acting on my own behalf, and that the foregoing statements are true and correct to the best of my knowledge and belief.

______________________

(Signature of Affiant)

State of___________________________________________________ County of__________________________________________________ Personally appeared before me the above named ______________________ personally known to me, who, being duly sworn, deposes and says that he/she executed the above instrument and that the statements and answers contained therein are true and correct to the best of his/her knowledge and belief.

Subscribed and sworn to before me this ____________________ day of _______________________ 19____.

_____________________

(Notary Public)

(SEAL) My Commission Expires ____________________

JOHN W. OXENDINE

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

CHECKLIST OF APPLICATION DOCUMENTS

FOR CERTIFICATION OF PRIVATE REVIEW AGENTS

Name of organization:______________________________________

(Please file your documents in the same order as the checklist) (check or n/a)

______ 1. Are all applicable organizational documents (original copy or certified copy of the original) including all amendments to those documents attached?

______ a. Partnership Agreement

______ b. Articles of Incorporation (certified by your Secretary of State)

______ c. Trade Name Certificate

______ d. Trust Agreement

______ e. Other __________________________

______ 2. Are the bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal attached?

______ 3. Is one copy of the Biographical Affidavit (GID-65(UR)) for each of the individuals responsible for the conduct of the affairs of the private review agent attached?

______ 4. Is the private review agent using a fictitious or "dba" name? If so, is a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business attached?

______ 5. Was the private review agent operating in Georgia prior to the effective date of this Regulation?

_________ yes _________ no

If so, was the certification applied for within sixty (60) days of such effective date?

_________ yes _________ no

______ 6. Have the original license or certificate fee and application fee been enclosed? (Please make checks payable to the Commissioner of Insurance)

______ 7. If a renewal, was it applied for no sooner than ninety (90) days prior to the certification expiration date?

______ a. Was the application for renewal submitted on Forms GID-57, GID-65(UR) and GID-72?

______ b. Has the renewal license or certificate fee been received?

______ 8. Is the utilization review plan attached?

______ 9. Is a statement or documentation that the private review agent has received full accreditation by URAC attached?

______ 10. If your organization is not fully accredited by URAC, have you attached the reasons why full accreditation has not been obtained?

______ 11. Is a description of the type, qualifications and number of the personnel, either employed or under contract, to perform utilization review attached?

______ 12. Is a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan attached?

______ 13. Is a written description of an ongoing quality assessment program attached?

______ 14. Are the written policies and procedures to ensure that a representative of the private review agent is reasonably accessible to patients and providers five (5) days a week during normal business hours in this state attached?

______ 15. Are the written policies and procedures to ensure compliance with all state laws and regulations to protect the confidentiality of information obtained in the course of utilization review attached?

______ 16. Are the written policies and procedures for establishing and maintaining a complaint system attached?

______ 17. Is a sample John Doe copy of each type of contract or agreement to be executed between the private review agent and payor, employer, claim administrator, or other entity with certification that no incentive payment provision exists in these contracts or agreements for the private review agent based on reduction of services or the charges thereof, reduction of length of stay, or utilization of alternative treatment settings to reduce amounts of necessary or appropriate medical care attached?

______ 18. Is the Application for Certification as a Private Review Agent Form GID-57 completed and attached?

______ 19. Are the Biographical Affidavits on Form GID-65(UR) completed and attached?

______ 20. Is the Checklist of Application Documents Form GID-72 completed and attached?

______ 21. Are all the appropriate areas in the application signed and notarized or certified?

If you are an individual with a disability and wish to acquire this document in an alternative format, please contact the ADA Coordinator, Office of Commissioner of insurance, 2 Martin Luther King, Jr., Dr., Atlanta, Georgia 30334. (404) 656-2056 - TDD (404) 656-4031.

JOHN W. OXENDINE

OFFICE OF COMMISSIONER OF INSURANCE

STATE OF GEORGIA

ATLANTA, GEORGIA

ANNUAL REPORT INFORMATION FOR UTILIZATION

REVIEW ACTIVITIES

FOR THE YEAR ENDED ____________

(Typewritten Only)

If you are an individual with a disability and wish to acquire this application in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King, Jr. Drive, Atlanta, Georgia 30334 (404) 656-2056 / TDD (404) 656-4031

This information is necessary for the annual report which is required under O.C.G.A. Section 33-46-14 to assess utilization review operations and the extent to which these practices actually affect patients in Georgia. This form is distributed to each private review agent. The information obtained will be summarized providing an overall picture of the "State of Utilization Review in Georgia."

Background Information

1. Legal name and address of private review agent:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

2. Telephone number: (______)___________________

Fax number: (______)________________

3. Name, title and phone number of designated contact person responsible for this information:

______________________________________________________

______________________________________________________

4. Indicate the year in which your organization was established: _________ Indicate the year in which your organization began operations in Georgia: __________

5. Is your organization independently owned or is it a subsidiary of or owned by another organization? Independently owned ______ (SKIP TO NEXT SECTION)

A subsidiary of or owned by another organization _____

6. Does the parent organization or any of its subsidiaries provide direct patient care?

yes _________ no ________

7. Is the parent organization or any of its subsidiaries a health insurer?

yes _________ no ________

8. Has the parent organization or any of its subsidiaries ever purchased any of your utilization review services?

yes _________ no ________

Services Performed

1. Indicate the estimated percentage distribution of clinical services reviewed:


                image: ga/admin/2020/120-2-58-.09_001.gif

2. Indicate the total acute care hospital admissions reviewed: ___________________________________________

3. Indicate the percent of proposed admissions diverted for outpatient care: ________________________________

4. Indicate the volume of reviews annually performed: prospective (precertification) _______________ concurrent (continued stay) _______________ restrospective _______________ other _______________

5. Indicate the total number of Georgia lives covered for each entity for whom the private review agent performs utilization review services:

Entity # Georgia lives covered

a. Employers _________________

b. Payors (Insurers) _________________

c. Claim administrators _________________

d. Others _________________

6. Indicate if your organization performs the following types of review and the percentage performed telephonically and/or on-site;

Telephonic On site

Prospective Review yes no ________% ________%

Concurrent Stay Review yes no ________% ________%

Discharge Planning yes no ________% ________%

Case Management yes no ________% ________%

7. How many reviews does your organization conduct on average, per episode of care?

prospective ________

concurrent ________

retrospective ________

other ________

Utilization Review Staff

1. Personnel who conduct reviews.

(A) For each type, please indicate if, at any phase of the utilization review process, any of that staff type made decisions about the necessity or the appropriateness of requested medical or surgical care for your organization for the preceding calendar year.

(B) If "yes," please enter the total number of staff of each type that made these decisions, and the number of staff that were full-time employees of your organization, part-time employees of your organization who worked on the premises of your organization, part-time employees of your organization who worked off the premises of your organization, and consultants/advisors to your organization. (IF NONE, ENTER "0")

Form GID-73


                image: ga/admin/2020/120-2-58-.09_002.jpg


                image: ga/admin/2020/120-2-58-.09_003.jpg

2. List the board specialties (as recognized by the American Board of Medical Specialists) for the number of staff physicians and the number of consultants/advisors for the organization. (i.e. Family Practice, Internal Medicine, Pediatrics, etc.) Also, indicate the same for staff recognized by the Advisory Board of Osteophatic Specialist.


                image: ga/admin/2020/120-2-58-.09_004.gif

Utilization Review and Appeals

1. CASE MANAGEMENT

a. During the preceding calendar year, did your organization review any catastrophic medical or surgical cases to determine the need for case management services; that is, determine the need for coordinated care for patients requiring expensive or extended care?

yes no ________________________ no ____________________

(SKIP TO QUESTION 2)

b. How many cases did you screen for case-management?_______________________

c. How many of these cases were recommended for case-management?

_______________________________________________________

_______________________________________________________

d. How many were ultimately case-managed?

_______________________________________________________

2. Please list the top five surgeries or procedures that your organization most often did not authorize during the preceding calendar year because of unsubstantiated medical need.

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

3. Indicate the number and outcome by clinical service (i.e. medical, surgical, maternity, etc.) of each appeal as addressed in Rule 120-2-58-.05, entitled "Requirements for Utilization Review", paragraph (6)(b).

________________________________________________________

________________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

________________________________________________________

_______________________________________________________

4. The average number of days required to complete each level of appeal:

________________________________________________________

________________________________________________________

ACKNOWLEDGEMENT

The Office of Commissioner of Insurance expresses its gratitude and appreciation to the United States General Accounting Office for granting permission to use some material from their study entitled "Information on Utilization Review Organizations." GAO/HRD-93-22FS.