Ga. Comp. R. & Regs. R. 120-2-58-.06 - Complaint Procedure
Private review agents shall establish and maintain a complaint system which includes, at a minimum, the following:
(a) Establishes and maintains a complaint
system which has been approved by the Commissioner and which provides
reasonable procedures for the resolution of written complaints initiated by
enrollees covered persons or health care healthcare providers concerning
utilization review;
(b) Maintains
records of such written complaints for five years from the time the complaints
are filed and submits to the Commissioner a summary report at such times and in
such format as the Commissioner may require; and
(c) Permits the Commissioner to examine the
complaints at any time
(d) All
complaints shall be directed to the private review agent; and
(e) The private review agent shall contact
the complainant, gather all pertinent facts regarding the complaint, and
attempt to resolve the complaint as soon as reasonably possible within the
context of written policies and procedures.
Notes
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