Ga. Comp. R. & Regs. R. 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 a clinical peer, an identified health
care provider representing the private review agent and trained in a related
healthcare 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.
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.