Rule 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 § 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.Ga. Comp. R. & Regs. R. 120-2-80-.07
O.C.G.A. Secs. 33-2-9, 33-20A-2, 33-20A-4, 33-20A-5, 33-46-2, 33-46-4.
Original Rule entitled "Utilization Review" adopted. F. Mar. 20, 1998; eff. Apr. 9, 1998.Amended: F. June 5, 2002; eff. June 25, 2002.