Ga. Comp. R. & Regs. R. 120-2-80-.07 - Utilization Review
(1) 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
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120-2-58-.03(2).
(2) 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.
(3) 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.
(4) 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.
(5) 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.
Notes
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