2010 Georgia Code
TITLE 33 - INSURANCE
CHAPTER 46 - CERTIFICATION OF PRIVATE REVIEW AGENTS
§ 33-46-4 - Requirements for certification

O.C.G.A. 33-46-4 (2010)
33-46-4. Requirements for certification


As a condition of certification or renewal thereof, a private review agent shall be required to maintain compliance with the following:

(1) The medical protocols including reconsideration and appeal processes as well as other relevant medical issues used in the private review program shall be established with input from health care providers who are from a major area of specialty and certified by the boards of the American medical specialties selected by a private review agency and shall be made available upon request of health care providers; or protocols, including reconsideration and appeal processes as well as other relevant health care issues used in the private review program, shall be established based on input from persons who are licensed in the appropriate health care provider's specialty recognized by a licensure agency of such a health care provider;

(2) All preadmission review programs shall provide for immediate hospitalization of any patient for whom the treating health care provider determines the admission to be of an emergency nature, so long as medical necessity is subsequently documented;

(3) In the absence of any contractual agreement between the health care provider and the payor, the responsibility for obtaining precertification as well as concurrent review required by the payor shall be the responsibility of the enrollee;

(4) In cases where a private review agent is responsible for utilization review for a payor or claim administrator, the utilization review agent should respond promptly and efficiently to all requests including concurrent review in a timely method and a method for an expedited authorization process shall be available in the interest of efficient patient care;

(5) In any instances where the utilization review agent is questioning the medical necessity or appropriateness of care, the attending health care provider shall be able to discuss the plan of treatment with an identified health care provider trained in a related specialty and no adverse determination shall be made by the utilization review agent until an effort has been made to discuss the patient's care with the patient's attending provider during normal working hours. In the event of an adverse determination, notice to the provider and patient will specify the reasons for the review determination;

(6) To the extent that utilization review programs are administered according to recognized standards and procedures, efficiently with minimal disruption to the provision of medical care, additional payment to providers should not be necessary;

(7) A private review agent shall assign a reasonable target review period for each admission promptly upon notification by the health care provider. Once a target length of stay has been agreed upon with the health care provider, the utilization review agent will not attempt to contact the health care provider or patient for further information until the end of that target review period except for discharge planning purposes or in response to a contact by a patient or health care provider. The provider or the health care facility will be responsible for alerting the utilization review agent in the event of a change in proposed treatment. At the end of the target period, the private review agent will review the care for a continued stay;

(8) A private review agent shall not enter into any incentive payment provision contained in a contract or agreement with a payor which is based on reduction of services or the charges thereof, reduction of length of stay, or utilization of alternative treatment settings; and

(9) Any health care provider may designate one or more individuals to be contacted by the private review agent for information or data. In the event of any such designation, the private review agent shall not contact other employees or personnel of the health care provider except with prior consent to the health care provider. An alternate will be available during normal business hours if the designated individual is absent or unavailable.

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