Rules and Regulations of the State of Georgia
 

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  • 1. In the address bar, type about:config and press Enter.
  • 2. Click "I'll be careful, I promise" if a warning message appears.
  • 3. In the search box, search for javascript.enabled
  • 4. Toggle the "javascript.enabled" preference (right-click and select "Toggle" or double-click the preference) to change the value from "false" to "true".
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  1. On web browser menu click "Tools" icon and select "Internet Options".
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 Internet Explorer < 9
  1. On web browser menu click "Tools" and select "Internet Options"
  2. In the "Internet Options" window select the "Security" tab.
  3. On the "Security" tab click on the "Custom level..." button.
  4. When the "Security Settings - Internet Zone" dialog window opens, look for the "Scripting" section.
  5. In the "Active Scripting" item select "Enable".
  6. When the "Warning!" window pops out asking "Are you sure you want to change the settings for this zone?" select "Yes".
  7. In the "Internet Options" window click on the "OK" button to close it.
  8. Click on the "Refresh" button of the web browser to refresh the page.
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chrome Google Chrome

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  5. Click on the "OK" button to close it.
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opera Opera

  • 1. a) Click on "Menu", hover mouse on the "Settings" then hover mouse on the "Quick preferences" and mark the "Enable Javascript" checkbox.
  • 1. b) If "Menu bar" is shown click on the "Tools", hover mouse on the "Quick preferences" and mark the "Enable Javascript" checkbox.
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safari Apple Safari

  1. On the web browser menu click on the "Edit" and select "Preferences".
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  3. In the "Security" tab section "Web content" mark the "Enable JavaScript" checkbox.
  4. Click on the "Reload the current page" button of the web browser to refresh the page.
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<xmp>.</xmp> <form name="form1" method="post" action="120-2-80?urlRedirected=yes&amp;data=admin&amp;lookingfor=120-2-80" id="form1"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="/wEPDwUKLTY5ODkwOTM2Nw8WAh4Ec3BhbQIJFgJmD2QWAgIFDw8WAh4EVGV4dAUFMSArIDhkZGSYdGchgw7NwTk2wBoq2g1NK/iNcQ==" /> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="EEBB6393" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="/wEWCALtvMykBwLniKOhBALV5cpNAoa5iIEFAoznisYGAsrv5u0MAsrv4u0MAsrv3u0MuqC/93pxP8cZBe6ScdL8WSNlE+E=" /> <div class='popup'> <div class='cnt223'> <div style="margin-bottom:6px;"> <img alt="Rules and Regulations of the State of Georgia" src="/images/new.gif"/> </div> <div class="header"> Terms and Conditions of Agreement for Access to Rules and Regulations of the State of Georgia Website </div> <div class="scroll"> <p>(Note: certain features of this site have been disabled for the general public to prevent digital piracy. If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree that you will not copy, print, or download anything from this website for any commercial use. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website.</p> <p> You agree that you will not sell, will not license, and will not otherwise make available in exchange for anything of value, anything that you download, print, or copy from this site.</p> <p> You agree that you will not copy, print, or download any portion of the regulations posted on this site exceeding a single chapter of regulations for sale, license, or other transfer to a third party, except that you may quote a reasonable portion of the regulations in the course of rendering professional advice.</p> <p> If you violate this agreement, or if you access or use this website in violation of this agreement, you agree that Lawriter will suffer damages of at least $20,000. </p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." 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If you are an entitled government entity pursuant the Georgia Administrative Procedures Act, <a target="_new" href="http://links.casemakerlegal.com/states/GA/books/Code_of_Georgia/browse?ci=25id=gasos&amp;codesec=50-13-7&amp;title=50&amp;#50-13-7(d)">O.C.G.A.§ 50-13-7(d)</a> contact the State of Georgia's Administrative Procedures Division at 678-364-3785 to enable these features for your location.)</p> <p>To access this website, you must agree to the following: </p> <p> These terms of use are a contract between you and/or your employer (if any), and Lawriter, LLC. </p> <p> You agree not to use any web crawler, scraper, or other robot or automated program or device to obtain data from the website. </p> <p> You agree that you will not sell or license anything that you download, print, or copy from this website.</p> <p> THIS WEBSITE AND ITS CONTENT ARE PROVIDED "AS IS." THE STATE OF GEORGIA AND LAWRITER EXPRESSLY DISCLAIM ALL WARRANTIES, INCLUDING THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT AND ARE NOT LIABLE TO ANY PERSON FOR ANY ERRORS IN INACCURACIES CONTAINED IN THIS WEBSITE. </p> <p> By accessing and/or using this website, you agree to the terms and conditions above. If you do not agree to the terms and conditions above, you must cease accessing and/or using this website and destroy all material obtained from this website without your agreement. </p> </div> </div> <div class="modal-footer"> <input type="button" name="btnAgree" value="Close" id="btnAgree" class="btn-blue noprint" /> <input type="button" name="btnprint" value="Print" id="btnprint" class="btn-blue noprint" /> </div> </div> </div> <div id="main" class="noprint"> <!--class="noprint"--> <div id="header" class="noprint"> <div class="container"> <div class="terms"> NOTICE OF TERMS OF USE OF THIS WEBSITE. 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charset=UTF-16"> </HEAD> <div id="infobar"><a href="javascript:;" accesskey="r" Name="Route" title="Route" class="quickkey"><em class="mnemonic">R</em>oute </a>:<div class="searchtips" style="float:right;margin-right:10px;color: rgb(47, 79, 79);"> <a style="text-decoration:none;color: rgb(47, 79, 79);" title="search tips" name="searchtip" href="../help.aspx#searching" target="_blank"><em class="mnemonic">S</em>earch tips</a></div><ul class="breadcrumb"> <li><a href="/GAC" name="GAC" title="GAC">GA R&amp;R</a></li> <li>&raquo; <a href="/GAC/120" title="120">Department 120</a></li> <li>&raquo; <a href="/GAC/120-2" title="120-2">Chapter 120-2</a></li> <li>&raquo; Subject 120-2-80</li> </ul> </div> </div><div id="doc" class="container"> <div id="doc-content" class="content"> <h1><nllsubject>Subject 120-2-80 PATIENT PROTECTION ACT</nllsubject></h1> <h2><a href="/GAC/120-2-80-.01" name="120-2-80-.01" title="120-2-80-.01">Rule 120-2-80-.01 Scope</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.01(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> This Regulation Chapter shall apply to licensed insurers, including, but not limited to, health maintenance organizations and health care corporations offering managed care plans in this State.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.01(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Insurers with approved or proposed policy contracts containing preferred provider arrangements subject to O.C.G.A. Title 33, Chapter 30, Article Two, shall be subject to this Regulation Chapter and shall be considered managed care entities. Preferred Provider Organization plans shall be subject to the provisions of this Regulation Chapter as may be reasonably applied to covered benefits and services offered through a managed care entity's contracting, participating preferred providers.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.01(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Where enrollees of managed care plans choose to obtain covered benefits or services outside the panel of contracting or preferred providers, a managed care entity shall not be held responsible for access, credentialing, quality of care or other issues not under the insurer's control because of lack of provider contracting status. Managed care entities should disclose plan provisions and limitations regarding benefits, access and quality issues in these instances.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.01(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Nothing in this Regulation Chapter shall be construed to permit any person other than a licensed insurer to offer a managed care plan or other insurance product or allow an entity or person to transact insurance in this State without a Certificate of Authority as provided in O.C.G.A. Title 33, Chapter 3.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.01(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Nothing in this Regulation Chapter or O.C.G.A. Title 33, Chapter 20A shall be construed to create new classes of insurance pursuant to O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-3-5&amp;title=33#" target="_newtab">33-3-5</a> or new lines of insurance pursuant to Title 33, Chapter 7.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.02" name="120-2-80-.02" title="120-2-80-.02">Rule 120-2-80-.02 Definitions</a></h2> <P>Definitions under this Regulation Chapter shall have the meaning as set forth in the Georgia Insurance Code or the Rules and Regulations of the Office of Commissioner of Insurance, unless indicated below:</P> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Appeal" shall mean a formal request, either orally, or in writing or by electronic transmission, to reconsider a determination not to certify an admission, extension of stay, or other health care service or procedure, and shall include both formal standard appeals and expedited appeals.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Complaint" shall mean a communication from the enrollee or member either orally, in writing or by electronic transmission concerning dissatisfaction by the enrollee or member with the health plan or its providers.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Grievance Procedure" shall mean a hearing provided to the enrollee, pursuant to O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-20A-5&amp;title=33#33-20A-5(3)(B)(ii)" target="_newtab">33-20A-5(3)(B)(ii)</a>, regarding denial of payment in whole or in part for a health care service, treatment or claim, following exhaustion of all standard appeals requirements contained in O.C.G.A. Title 33, Chapter 46 or the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Managed Care Contractor" shall have the meaning set forth at O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-20A-3&amp;title=33#33-20A-3(5)" target="_newtab">33-20A-3(5)</a> and shall include entities unaffiliated with a managed care entity providing network administrative, credentialling, utilization review or medical management services for the operation of one or more managed care plans.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Managed Care Entity" shall have the meaning set forth at § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-20A-3&amp;title=33#33-20A-3(6)" target="_newtab">33-20A-3(6)</a> and shall include all insurers, health maintenance organizations, health care corporations, multiple employer welfare arrangements, or other entities which are subject to licensure by the Commissioner.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.02(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> "Stabilize", with respect to an emergency medical condition, shall mean to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual to or from a facility.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.03" name="120-2-80-.03" title="120-2-80-.03">Rule 120-2-80-.03 Application</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.03(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Managed care entities may make application for a managed care plan or plans to be certified under this Regulation Chapter by submitting Form GID PPA-1 with a filing fee of $500.00.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.03(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The Commissioner shall have ninety (90) days after receipt of the application in which to review the application. During this period the Commissioner may request additional information as necessary. The Commissioner may extend the time in which to review an application by contacting the applicant in writing and he or she is not required to act on an incomplete application.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.03(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Managed care entities with previously approved managed care plans in use in this state as of the effective date of this Regulation Chapter must submit applications for certification no later than ninety (90) days after the effective date of this Regulation Chapter. Managed care entities making timely filing of an application for certification of previously approved managed care plans may continue to offer such plans until the Commissioner determines such plans do not comply with the requirements of the Patient Protection Act or this Regulation Chapter.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.03(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Managed care entities making application for certification of managed care plans which are not yet approved may not offer such managed care plans until the application for certification under this Regulation Chapter is approved and the managed care product is approved in accordance with other requirements under O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-24-9&amp;title=33#" target="_newtab">33-24-9</a> as well as any other applicable laws and Regulation Chapters. This requirement for prior certification shall apply to all managed care plans not offered by the effective date of this Regulation Chapter.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.03(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Within the discretion of the Commissioner, managed care entities which have attained accreditation or which use managed care contractors accredited by national boards, committees or other accepted industry standard setting organizations may satisfy some or all of the requirements for certification.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.04" name="120-2-80-.04" title="120-2-80-.04">Rule 120-2-80-.04 Modification of Operation of Plan after Certification</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity shall file supporting documentation for any substantial modification of its managed care plan or plans with the Commissioner. Such documentation shall describe changes in operations and update any previous filings made by the managed care entity for the affected managed care plan or plans. Substantial modification includes, but is not limited to, the following: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(1)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Broad substitution, merger or other change in hospital, physician network or ancillary services provider or network;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(1)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Changes in subcontracting providers for utilization review or administrative services; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(1)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Other changes affecting the content, rules or procedures of any of the above entities.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> All proposed substantial modifications which are voluntary must be submitted for the Commissioner's approval at least sixty (60) days prior to proposed changes, and must clearly indicate the nature, level and scope of changes. Managed care entities may not adopt substantial modifications which are voluntary prior to receiving approval from the Commissioner.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.04(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Modifications reflecting changes not under the control of the managed care entity should be filed with the Commissioner as soon as possible.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.05" name="120-2-80-.05" title="120-2-80-.05">Rule 120-2-80-.05 Reporting Requirements</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Managed care entities with annual and quarterly statement requirements which report premiums and claims, enrollment, utilization of services, numbers of contracting providers and numbers of complaints and grievances shall continue to capture and report this information on standard financial and other required reporting formats as they relate to managed care plans under this Regulation Chapter.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Managed care entities not subject to specific reporting requirements for their managed care plans shall gather and prepare such information on a quarterly and annual basis as is necessary to capture and report, including, but not limited to: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> premiums and claims;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> enrollment;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> utilization of services; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> numbers of contracting providers; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.05(2)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> numbers of complaints and grievances. <P>These reports shall be marked as "Patient Protection Act Statistical Reports" and shall bear the name and NAIC number of the reporting entity, and shall be submitted as supplements to normal quarterly and annual financial reports presently required. The Commissioner, at his or her discretion, may specify additional reporting requirements for managed care plans.</P> </td> </tr> </table> </td> </tr> </table> <h2><a href="/GAC/120-2-80-.06" name="120-2-80-.06" title="120-2-80-.06">Rule 120-2-80-.06 Emergency Services, Stabilization</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> As used in this section, the term "emergency services" or "emergency condition" shall have the same meaning as set forth in O.C.G.A. § <a href="https://links.casemakerlegal.com/states/ga/books/Code_of_Georgia/browse?ci=25&amp;id=gasos&amp;codesec=33-20A-3&amp;title=33#33-20A-3(2)" target="_newtab">33-20A-3(2)</a>.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> No managed care plan may require, as a condition of receiving emergency services, that a covered person seek prospective authorization. This prohibition against prior authorization extends to such time as the covered person is stabilized for such emergency condition.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity shall include provisions in its managed care plans describing: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Coverage for emergency services;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Any out of pocket, copayment, or other expenses which may accrue to a covered person;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> Provisions for out of network and out of service area emergency services;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The terms "authorization" or "prospective authorization" as they relate to the covered person, including how such authorization procedures will apply and be administered if sought by the covered person in an emergency even though not required; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(3)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A covered person's or provider's review or appeal rights in accordance with O.C.G.A. Title 33, Chapter 46 and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58, in the event that the managed care entity does not pay for emergency services obtained by the covered person.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity shall include provisions in its provider contracts defining and describing prospective authorization or other authorization as they relate to a contracting or participating provider.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity which authorizes the delivery of emergency services for evaluation, diagnostic testing or treatment provided as a part of intervention, whether for evaluation or stabilization purposes, shall not subsequently deny payment in accordance with the coverage of the managed care plan.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(6)">(6)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity may review delivery of emergency services for purposes of payment or reimbursement only if: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(6)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> there is reason to believe, pursuant to subsequent evidence, such services were not medically necessary nor appropriate in accordance with established medical criteria and the requirements of Title 33, Chapter 46 and the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58; or</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(6)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> the individual receiving such care should have known, as a prudent layperson, possessing an average knowledge of medicine and health, that an emergency medical condition did not exist.</td> </tr> </table> </td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.06(7)">(7)</a></td> <td valign="top" style="text-align:left" class="leftalign"> If a participating provider or other authorized representative of a managed care entity authorizes emergency services as permitted by the terms of the managed care plan or the terms of the provider contract, the managed care entity shall not subsequently review such emergency services for purposes of payment or reimbursement or retract its authorization after the emergency services have been provided, unless the authorization was based on a material misrepresentation about the covered person's health condition which was made by the covered person or the provider of emergency services.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.07" name="120-2-80-.07" title="120-2-80-.07">Rule 120-2-80-.07 Utilization Review</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.07(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 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 § <a title="120-2-58" href="120-2-58">120-2-58</a>-.03(2).</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.07(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 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.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.07(3)">(3)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 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.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.07(4)">(4)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 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.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.07(5)">(5)</a></td> <td valign="top" style="text-align:left" class="leftalign"> 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.</td> </tr> </table> <h2><a href="/GAC/120-2-80-.08" name="120-2-80-.08" title="120-2-80-.08">Rule 120-2-80-.08 Quality Assurance</a></h2> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(1)">(1)</a></td> <td valign="top" style="text-align:left" class="leftalign"> A managed care entity shall disclose the quality assurance program in effect with documentation specified in Form GID PPA-1.</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)">(2)</a></td> <td valign="top" style="text-align:left" class="leftalign"> The managed care entity must demonstrate, to the satisfaction of the Commissioner, that its quality assurance program includes organizational arrangements and ongoing procedures for the identification, evaluation, resolution and follow up of potential and actual problems in health care administration and delivery to enrollees. The program should include, but not be limited to procedures to: <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(a)">(a)</a></td> <td valign="top" style="text-align:left" class="leftalign"> monitor and resolve complaints;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(b)">(b)</a></td> <td valign="top" style="text-align:left" class="leftalign"> monitor provider performance;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(c)">(c)</a></td> <td valign="top" style="text-align:left" class="leftalign"> monitor patient satisfaction;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(d)">(d)</a></td> <td valign="top" style="text-align:left" class="leftalign"> establish appropriate quality indicators based on current standards of the relevant health care profession;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(e)">(e)</a></td> <td valign="top" style="text-align:left" class="leftalign"> meet reasonable thresholds with regard to quality indicators;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(f)">(f)</a></td> <td valign="top" style="text-align:left" class="leftalign"> credential network providers according to established standards;</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(g)">(g)</a></td> <td valign="top" style="text-align:left" class="leftalign"> ensure access to network providers by maintaining sufficient numbers of primary care physicians and other types of providers within the managed care entity's service area; and</td> </tr> </table> <table border="0" width="100%" cellspacing="4" cellpadding="4"> <tr> <td valign="top" width="1%" style="white-space:nowrap;text-align:left;width:18px;"><a style="white-space:nowrap;" name="120-2-80-.08(2)(h)">(h)</a></td> <td valign="top" style="text-align:left" class="leftalign"> detect both under utilization and over utilization of services.</td> </tr> </table> </td> </tr> </table> <h2><a href="/GAC/120-2-80-.09" name="120-2-80-.09" title="120-2-80-.09">Rule 120-2-80-.09 Confidentiality</a></h2> <P>A managed care entity shall demonstrate, as provided in Form GID PPA-1, that it has in place procedures designed to assure compliance with all applicable state and federal laws regarding the confidentiality of patient information and reporting requirements.</P> <h2><a href="/GAC/120-2-80-.10" name="120-2-80-.10" title="120-2-80-.10">Rule 120-2-80-.10 Examination</a></h2> <P>The Commissioner is authorized to examine insurers and other entities in matters related to managed care plans under the Patient Protection Act and this Regulation Chapter.</P> <h2><a href="/GAC/120-2-80-.11" name="120-2-80-.11" title="120-2-80-.11">Rule 120-2-80-.11 Penalties</a></h2> <P>Any person failing to comply with the requirements of this Regulation Chapter shall be subject to such penalties as may be appropriate under the insurance laws of this State.</P> <h2><a href="/GAC/120-2-80-.12" name="120-2-80-.12" title="120-2-80-.12">Rule 120-2-80-.12 Severability</a></h2> <P>If any section or portion of a section of this rule or the applicability thereof to any person or circumstance is held invalid by a court, the remainder of the rule or the applicability of such portion to other persons or circumstances shall not be affected thereby.</P> </div> </div> </HTML> </div> <div id="toc" class="sidebar noprint"> <ul id="toc-children" class="children"><li><a href="/GAC/120-2-80-.01" name="120-2-80-.01" title="120-2-80-.01">Rule 120-2-80-.01 Scope</a></li><li><a href="/GAC/120-2-80-.02" name="120-2-80-.02" title="120-2-80-.02">Rule 120-2-80-.02 Definitions</a></li><li><a href="/GAC/120-2-80-.03" name="120-2-80-.03" title="120-2-80-.03">Rule 120-2-80-.03 Application</a></li><li><a href="/GAC/120-2-80-.04" name="120-2-80-.04" title="120-2-80-.04">Rule 120-2-80-.04 Modification of Operation of Plan after Certification</a></li><li><a href="/GAC/120-2-80-.05" name="120-2-80-.05" title="120-2-80-.05">Rule 120-2-80-.05 Reporting Requirements</a></li><li><a href="/GAC/120-2-80-.06" name="120-2-80-.06" title="120-2-80-.06">Rule 120-2-80-.06 Emergency Services, Stabilization</a></li><li><a href="/GAC/120-2-80-.07" name="120-2-80-.07" title="120-2-80-.07">Rule 120-2-80-.07 Utilization Review</a></li><li><a href="/GAC/120-2-80-.08" name="120-2-80-.08" title="120-2-80-.08">Rule 120-2-80-.08 Quality Assurance</a></li><li><a href="/GAC/120-2-80-.09" name="120-2-80-.09" title="120-2-80-.09">Rule 120-2-80-.09 Confidentiality</a></li><li><a href="/GAC/120-2-80-.10" name="120-2-80-.10" title="120-2-80-.10">Rule 120-2-80-.10 Examination</a></li><li><a href="/GAC/120-2-80-.11" name="120-2-80-.11" title="120-2-80-.11">Rule 120-2-80-.11 Penalties</a></li><li><a href="/GAC/120-2-80-.12" name="120-2-80-.12" title="120-2-80-.12">Rule 120-2-80-.12 Severability</a></li></ul> </div> </div> <!--content ends here--> <div id="footer" class="noprint"><span class="footer">Copyright &copy; 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