Rule 120-2-83-.04 - Provider Nomination(a) Managed care entities shall create, and make readily available to nominated providers, a nomination package which shall include, if applicable: (1) Information regarding credentialing procedures pursuant to Rule 120-2-83-.05. This includes, but is not limited to, all forms required to be completed by the provider for the purpose of credentialing; and(2) A compensation schedule specific to the nominated provider's area of practice.(b) Managed care entities shall accept the nomination form referenced in Rule 120-2-83-.03(a) by any means that evidences the date and time of receipt.(c) Submission of the nomination form by the enrollee shall not constitute acceptance of the nominated provider by the managed care entity.(d) Within three (3) business days of receipt of the nomination form by the insurer, the managed care entity shall provide notice in writing, to the provider and the enrollee, of the provisional acceptance (in the case of managed care entities which will implement a credentialing process in accordance with Rule 120-2-83-.05), final acceptance (in the case of managed care entities which choose not to implement a credentialing process in accordance with Rule 120-2-83-.05), or the rejection of the nominated provider. In addition, the managed care entity shall make a good faith effort to provide the notice required by this paragraph by facsimile where practicable.(e) For deselected or rejected providers, the notice referred to in paragraph (d) shall contain specific statutory, medical, professional or ethical reasons for deselection or rejection. The provider may not be re-nominated by the enrollee unless the nomination form contains materially different information as determined by the provider or the managed care entity.(f) Nothing in this Rule shall be construed to limit the enrollee's right to emergency care as set forth in O.C.G.A. §§ 33-20A-3 and 33- 20A-9.(g) Accepted or provisionally accepted providers and enrollees shall be required to adhere to generally accepted rules of the managed care entity.(h) Accepted or provisionally accepted providers shall be reimbursed at the average contractual rate paid to similarly situated providers and such rates may differ from plan to plan offered by a managed care entity.(i) If a nominated provider will not be providing services at a hospital within the managed care entity's network, the enrollee must submit an additional nomination form for the hospital where services will be provided. Managed care entities shall include information regarding this requirement with the material supplied pursuant to Rule 120-2-83-.03(a). Nothing in this Rule shall require a provider to perform services only at hospitals within the managed care entity's network. Pursuant to O.C.G.A. § 33-20A-9.1(c)(1)(d), out of network hospitals must meet all other reasonable criteria as required by the managed care plan of in network hospitals.(j) Where a managed care entity provisionally accepts a nominated provider and then later deselects that provider based on the credentialing process in accordance with Rule 120-2-83-.05, the managed care entity is responsible for payment for covered services provided during the credentialing review period and before notice of the deselection of the nominated provider is received by the enrollee and the provider.(k) Nothing in this Rule shall prohibit a managed care entity from implementing alternate measures which are more beneficial to the enrollee as agreed to by the enrollee and managed care entity, providing the minimum requirements of this Rule are met.Ga. Comp. R. & Regs. R. 120-2-83-.04
O.C.G.A. Secs. 33-2-9, 33-20A-9.1.
Original Rule entitled "Provider Nomination" was f. as ER 120-2-83-0.10-.04. F. and eff. on November 24, 1999, the date of adoption, to remain in effect for 120 days or until the effective date of a permanent Rule covering the same subject matter is adopted, as specified by the Agency.Amended: Permanent Rule of same title adopted. F. Mar. 3, 2000; eff. Mar. 23, 2000.