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Rules and Regulations of the State of Georgia
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Subject 120-2-92 INDEPENDENT ACCREDITATION OF HEALTH MAINTENANCE ORGANIZATIONS

Rule 120-2-92-.01 Approved Accrediting Organizations List

The Commissioner shall establish a list of approved accreditation organizations for purposes of this regulation. A health maintenance organization which is accredited on a continuing basis by an organization on the Approved Accrediting Organizations List and meeting the other requirements of this regulation shall be deemed to have satisfied the requirements of O.C.G.A. § 33-21-3(b.1).

Rule 120-2-92-.02 Qualifications for Approved Accreditation Organizations

(1) An organization may become an approved accrediting organization for purposes of this regulation when it meets the following requirements:
(a) The organization has been in existence for a minimum of 10 years. An organization in existence for less than 10 years may petition the Commissioner for a waiver of this requirement;
(b) The organization is not owned or operated by a health maintenance organization and performs its accrediting functions independently from the control of health maintenance organizations;
(c) The organization operates on a national basis;
(d) The organization's board of directors is comprised of diverse health care, business and consumer interests, including but not limited to representatives of the medical profession, hospital industry, consumers, and health maintenance organizations;
(e) The organization has a process for regularly reviewing its own accreditation standards for health maintenance organizations;
(f) The organization has provisions to perform regular on-site reviews of health maintenance organizations;
(g) The organization establishes standards for performance and uses those standards to examine and measure the performance of health maintenance organizations in the following areas:
1. Quality Assurance and Improvement
2. Member Satisfaction
3. Appeals Processes
4. Clinical Oversight
5. Provider Credentialing
6. Utilization Review
7. Delegation Oversight
8. Confidentiality of Member Information
9. Access to Services.
(h) A copy of the organization's standards for accreditation must be made available to the Department of Insurance upon request. Revisions to such standards shall also be communicated to the Department. Such standards may be reviewed by the Department of Insurance on a triennial basis. The Department may request additional standards to be included within any approved organization's standards for accreditation.
(i) In each accreditation review, the organization must utilize a physician experienced in health maintenance organization quality assurance management;
(j) Upon request, the Department may review the accreditation review files for a licensed health maintenance organization.
(2) An organization seeking approval as an accrediting organization shall submit evidence to the Commissioner of its compliance with the standards in subparagraph (1) of this section. Upon submission of such evidence, the Commissioner, in his or her discretion, may include the organization on the Approved Accrediting Organizations List.

Rule 120-2-92-.03 Certification Pursuant to Accreditation by a National Accrediting Organization

(1) A health maintenance organization seeking certification for purposes of O.C.G.A. § 33-21-3(b.1) through proof of accreditation by a national accreditation organization shall:
(a) Submit to the Commissioner a copy of the certificate of provisional or final accreditation issued by a national accreditation agency qualified under this regulation; and
(b) Submit evidence that its services are reasonably available and accessible in its service area or proposed service area according to its written standards for establishing and measuring appropriate member access to health care services.
(2) For purposes of subparagraph (1)(a) of this section, a health maintenance organization may submit proof of accreditation of a company with which it is formally affiliated, provided that the affiliated company supervises or performs the services for the Georgia health maintenance organization using the same standards and procedures for which it has received accreditation by an Approved Accrediting Organization.

Rule 120-2-92-.04 Loss of Accreditation, Review and Action by the Commissioner of Insurance

(1) A health maintenance organization shall notify the Commissioner of Insurance of the loss of accreditation within 15 days of such occurrence.
(2) Upon receipt of notice of a health maintenance organization's accreditation, the Commissioner of Insurance shall notify the Commissioner of the Department of Human Resources.
(3) The Commissioner of Insurance may investigate and review specific issues relating to access and availability at any time.

Rule 120-2-92-.05 Severability

If any provision of this regulation or its application to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of the provision to other persons or circumstances shall not be affected.