§ 33-46-15. Exemptions From Applicability of Chapter
This chapter shall not apply to any contract with the federal government for utilization and review of patients eligible for hospital services under Title XVIII or XIX of the Social Security Act. This chapter shall not apply to any private review agent or utilization review entity when such private review agent or utilization review entity […]
§ 33-46-16. Commissioner to Issue Annual Report
The Commissioner shall issue an annual report to the Governor and the General Assembly concerning the conduct of utilization review in this state. Such report shall include a description of utilization review programs and the services they provide, an analysis of complaints filed against private review agents and utilization review entities by patients or providers, […]
§ 33-46-1. Construction
This chapter shall be construed liberally to promote consumer protection. History. Code 1981, § 33-46-1 , enacted by Ga. L. 2021, p. 629, § 2/SB 80. Editor’s notes. Ga. L. 2021, p. 629, § 1/SB 80, effective January 1, 2022, redesignated former Code Section 33-46-1, relating to legislative purposes and intent, as present Code Section […]
§ 33-46-20. Prior Authorization Requirements Posted on Website; Statistical Reporting
An insurer shall make any current prior authorization requirements readily accessible on its website to healthcare providers. Clinical criteria on which an adverse determination is based shall be provided to the healthcare provider at the time of the notification. If an insurer intends either to implement a new prior authorization requirement or to amend an […]
§ 33-46-2. Application
This chapter applies to: Private review agents; Utilization review entities; All health insurers and stand-alone dental plans that provide accident and sickness insurance products whether on an individual, group, or blanket basis as provided in this title; All administrators of such products licensed in accordance with Article 2 of Chapter 23 of this title; All […]
§ 33-46-21. Insurer Responsibility for Compliance; Periodic Reviews; Evaluation of Adverse Determinations
An insurer shall be responsible for monitoring all utilization review activities carried out by, or on behalf of, the insurer and for ensuring that all requirements of this chapter and applicable rules and regulations are met. The insurer also shall ensure that appropriate personnel have operational responsibility for the conduct of the insurer’s utilization review […]
§ 33-46-3. Legislative Purposes and Intent
The purpose of this chapter is to promote the delivery of quality healthcare in Georgia. Furthermore, it is to foster the delivery of such care in a cost-effective manner through greater coordination between healthcare providers, claim administrators, insurers, employers, patients, private review agents, and utilization review entities; to improve communication and knowledge of healthcare benefits […]
§ 33-46-22. Review of Appeals by Appropriate Healthcare Provider
A private review agent or utilization review entity shall ensure that all appeals are reviewed by an appropriate healthcare provider who shall: Possess a current and valid nonrestricted license or maintain other appropriate legal authorization; Be currently in active practice in the same or similar specialty and who typically manages the medical condition or disease; […]
§ 33-46-4. Definitions
As used in this chapter, the term: “Adverse determination” means a determination based on medical necessity made by a private review agent or utilization review entity not to grant authorization to a hospital, surgical, or other facility or to a healthcare provider’s office for admission, extension of an inpatient stay, or a healthcare service or […]
§ 33-46-23. Restrictions on Authorizations When Service Timely Rendered
If initial healthcare services are performed within 45 business days of approval of prior authorization, the insurer shall not revoke, limit, condition, or restrict such authorization, unless such prior authorization is for a Schedule II controlled substance or there is a billing error, fraud, material misrepresentation, or loss of coverage. History. Code 1981, § 33-46-23 […]