Rule 120-2-58-.06 - Complaint ProcedurePrivate 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.Ga. Comp. R. & Regs. R. 120-2-58-.06
O.C.G.A. §§ 33-2-9, 33-46-1, 33-46-11.
Original Rule entitled "Complaint Procedure" adopted. F. May 23, 1996; eff. June 12, 1996.Amended: F. June 29, 2022; eff. July 1, 2022, as specified by the Agency.