Ga. Comp. R. & Regs. R. 120-2-10-.03 - Medical or Surgical Policies-Outpatient Coverage
(1) In accordance with Section
33-29-6 of the Georgia Insurance
Code this rule is applicable to all individual accident and sickness policies
that provide coverage for medical or surgical procedures which are required to
be performed on an inpatient basis at a licensed hospital. These policies shall
contain provisions on their face or by endorsement to reimburse policyholders
for any otherwise covered medical or surgical procedures when such procedures
are performed on an outpatient basis in a facility described in said
policies.
(2) In ordinary
circumstances when the general condition of the patient would not be placed in
jeopardy, admission to the hospital as a registered bed patient may not be
necessary for the sole purpose of performing the procedures described
herein.
(3) All personnel and
providers of services shall be currently licensed to perform the services they
provide, when such services require licensure or registration under applicable
State laws.
(4) All facilities and
equipment needed and used for and in the delivery of services which are
required to be licensed and/or certified by law shall be so licensed and/or
certified.
(5) The medical or
surgical procedures listed in paragraph (7) below may be performed on an
outpatient basis unless the following situations exist which may contraindicate
the use of an outpatient setting:
(a) Presence
of medical conditions which make prolonged postoperative observation by a nurse
or skilled medical personnel a necessity (including but not limited to heart
disease and severe diabetes).
(b)
An unrelated procedure is being done simultaneously which itself requires
surgical hospitalization.
(c) Lack
of proper home postoperative care.
(d) Another surgical procedure could follow
the initial procedure (including but not limited to a one-stage breast biopsy
followed by a mastectomy).
(e)
Technical difficulties as documented by admission or operative notes.
(f) A specific State statute or State Agency
Rule(s) or Regulation(s) prohibits and/or limits said procedure.
(6) Upon the certification by the
Commissioner of Human Resources to the Insurance Commissioner that any
procedure listed in paragraph (7) below can no longer be legally and safely
performed on an outpatient basis, the Insurance Commissioner shall issue an
order suspending the listing of that procedure(s). Such suspension shall remain
in effect until such time as the Commissioner of Human Resources certifies to
the Insurance Commissioner that the procedure(s) so suspended may again be
legally and safely performed on an outpatient basis at which time the Insurance
Commissioner shall issue an order reinstating the listing of that procedure(s).
A copy of any such suspension and reinstatement orders shall be kept at the
offices of the Insurance Commissioner and provided at cost to any person
informing the Insurance Commissioner in writing of their desire to receive
copies of all such orders. The procedures listed as of the time of their
performances shall be reimbursable even if suspended at a subsequent
date.
(7) The numbers as set forth
below in the following subparagraphs represent the medical and surgical
services and procedures as contained in the Physician's Current
Procedural Terminology (CPT), Fourth Edition, 1977, as published by
the American Medical Association, Chicago, Illinois, 60610. Subject to the
above listed conditions, these listed procedures may be performed on an
outpatient basis.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.