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Rules and Regulations of the State of Georgia
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Subject 120-2-59 STANDARD CLAIM FORM FOR ACCIDENT AND SICKNESS INSURANCE

Rule 120-2-59-.01 Authority

This Regulation is issued pursuant to the authority vested in the Commissioner of Insurance by O.C.G.A. Sections 33-2-9 and 33-24-10.1.

Rule 120-2-59-.02 Purpose

The purpose of this Regulation Chapter is to implement the provisions of Chapter 24 of Title 33 of the Official Code of Georgia Annotated, provide for a standardized form to be used in the billing and reimbursement of health care, reduce the number of forms utilized and increase efficiency in the reimbursement of health care through standardization.

Rule 120-2-59-.03 Applicability and Scope

(1) Except as otherwise specifically provided, this Regulation Chapter shall apply to all issuers, health care practitioners, and institutional care practitioners.
(2) Nothing in this Regulation Chapter shall prohibit an issuer, health care practitioner or institutional care practitioner from using alternative forms or procedures for filing claims as are specified in a written contract between the health care practitioner or institutional care practitioner and issuer.

Rule 120-2-59-.04 Definitions

For the purposes of O.C.G.A. 33-24-10.1 and this Regulation Chapter:

(a) "HCFA" means the Health Care Financing Administration of the United States Department of Health and Human Services.
(b) "HCFA Form 1450" means the health insurance claim form maintained by HCFA for use by institutional care practitioners.
(c) "HCFA Form 1500" means the health insurance claim form maintained by HCFA for use by health care practitioners.
(d) "Health Care Practitioner" means a health care provider duly licensed by the Secretary of State of the State of Georgia pursuant to the Official Code of Georgia Annotated and the Rules and Regulations of the State of Georgia.
(e) "Institutional Care Practitioner" means a hospice, hospital, skilled nursing facility, extended care facility, intermediate care facility, convalescent nursing home, and personal care facility licensed pursuant to the Official Code of Georgia Annotated and the Rules and Regulations of the State of Georgia.
(f) "Insured" means an individual covered under a policy of insurance or the provider to which that individual has assigned benefits.
(g) "Issuer" means an insurance company, fraternal benefit society, health care service plan, health maintenance organization, third party administrator, and any other entity reimbursing the costs of health care expenses.
(h) "J512 Form" means the uniform dental claim form approved by the American Dental Association for use by dentists.

Rule 120-2-59-.05 Requirements

(1) Health care practitioners and institutional care practitioners shall use and accept the most current editions of the HCFA Form 1450, HCFA Form 1500, or J512 Form and most current instructions for these forms in the billing of patients or their representatives and filing claims with issuers.
(2) Issuers shall provide, upon request, to health care practitioners, institutional care practitioners and insureds, and accept the most current editions of the HCFA Form 1450, HCFA Form 1500, or J512 Form for the processing of claims.

Rule 120-2-59-.06 Severability

If any provision of this Regulation Chapter or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the Regulation Chapter and the application of such provision to other persons or circumstances shall not be affected thereby.


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