Title 33 — Title 33
0 chapters · 1,218 sections in this title.
O.C.G.A. § 33-20A-3 Definitions
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As used in this article, the term: (1) ‘‘Emergency services’’ or ‘‘emergency care’’ means those health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson, possess…
O.C.G.A. § 33-20A-30 Short title
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This article shall be known and may be cited as the ‘‘Patient’s Right to Independent Review Act.’’ History. — Code 1981, § 33-20A-30, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140.
O.C.G.A. § 33-20A-31 Definitions
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As used in this article, the term: (1) ‘‘Department’’ means the Department of Community Health established under Chapter 2 of Title 31. 809 33-20A-31 (2) ‘‘Eligible enrollee’’ means a person who: (A) Is an enrollee or an eligible dependent of an enrollee of a managed care plan or…
O.C.G.A. § 33-20A-32 Right to appeal
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An eligible enrollee shall be entitled to appeal to an independent review organization when: (1) The eligible enrollee has received notice of an adverse outcome pursuant to a grievance procedure or the managed care entity has not complied with the requirements of Code Section 33-…
O.C.G.A. § 33-20A-33 Experimental treatment
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Determining whether treatment is experimental, §33-20A-40. Favorable determination by independent review organization. Effect, §33-20A-37. Grievance procedure. Adverse outcome of grievance procedure. Request for independent review, §33-20A-35. 1276 INDEX MANAGED HEALTH CARE PLANS…
O.C.G.A. § 33-20A-34 Representatives for enrollee; cost of review; cooperation
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(a) The parent or guardian of a minor who is an eligible enrollee may act on behalf of the minor in requesting independent review. The legal guardian or representative of an incapacitated eligible enrollee shall be authorized to act on behalf of the eligible enrollee in requestin…
O.C.G.A. § 33-20A-35 Request for independent review
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(a) In the event that the outcome of the grievance procedure under Code Section 33-20A-5 is adverse to the eligible enrollee, the managed care entity shall include with the written notice of the outcome of the grievance procedure a statement specifying that any request for indepe…
O.C.G.A. § 33-20A-36 Additional information required for independent review
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(a) Within three business days of receipt of notice from the department of assignment of the application for determination to an independent review organization, the managed care entity shall submit to that organization the following: (1) Any information submitted to the managed …
O.C.G.A. § 33-20A-37 Effect of favorable determinations
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(a) A decision of the independent review organization in favor of the eligible enrollee shall be final and binding on the managed care entity and the appropriate relief shall be provided without delay. A managed care entity bound by such decision of an independent review organizat…
O.C.G.A. § 33-20A-38 Organizational and employee liability
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Neither an independent review organization nor its employees, agents, or contractors shall be liable for damages arising from determinations made pursuant to this article, unless an act or omission thereof is made in bad faith or through gross negligence, constitutes fraud or wil…
O.C.G.A. § 33-20A-39 Consumer
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Insurance underwriting and rate risking, §33-24-90. Consumer choice option. Managed health care plan, §33-20A-9.1. Consumer driven health plan.
O.C.G.A. § 33-20A-4 Standards
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Establishment, §33-20A-5. Confidentiality of information. Patient records, §33-20A-8. Conflicts of interest. Patient’s right to independent review. Independent review organization, §33-20A-39. Consumer choice option, §33-20A-9.1. Definitions, §33-20A-3. Consumers’ health insurance p…
O.C.G.A. § 33-20A-40 Determining medical necessity or whether a treatment is experimental
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(a) For the purposes of this article, in making a determination as to whether a treatment is medically necessary and appropriate, the expert reviewer shall use the definition provided in paragraph (7) of Code Section 33-20A-31. (b) For the purposes of this article, in making a det…
O.C.G.A. § 33-20A-41 Rules and regulations
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The department shall provide necessary rules and regulations for the implementation and operation of this article. History. — Code 1981, § 33-20A-41, enacted by Ga. L. 1999, p. 350, § 3; Ga. L. 2005, p. 1438, § 2/SB 140. 33-20A-42. Grievance procedures and hearings for Medicaid c…
O.C.G.A. § 33-20A-42 Short title, §33-20A-30
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PERSONAL PROPERTY. Insurance companies. Authority to sell, assign, transfer, etc., §33-11-38. Time limit for disposal, §33-11-40.
O.C.G.A. § 33-20A-5 Standards for certification
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The Commissioner shall establish standards for the certification of qualified managed care plans that conduct business in this state. Such standards must include the following provisions: (1) Disclosure to enrollees and prospective enrollees. (A) A managed care entity shall disclos…
O.C.G.A. § 33-20A-60 Definitions
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As used in this article, the term: (1) ‘‘Agent’’ shall not include an agent or agency as defined in Code Section 33-23-1. (2) ‘‘Carrier’’ means an accident and sickness insurer, fraternal benefit society, health care corporation, health maintenance organization, provider sponsored …
O.C.G.A. § 33-20A-61 Physician contracts
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(a) Every physician contract entered into, amended, extended, or renewed after July 1, 2002, by a carrier shall contain a specific provision which shall provide that, in the event that an insurance carrier, plan, network, panel, or any agent thereof should terminate a physician’s …
O.C.G.A. § 33-20A-62 Payment
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(a) No carrier, plan, network, panel, or any agent thereof may conduct a postpayment audit or impose a retroactive denial of payment on any claim by any claimant relating to the provision of health care services that was submitted within 90 days of the last date of service or dis…
O.C.G.A. § 33-20A-7 Drugs
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Restrictive formulary for prescription drugs. Requirements, §33-20A-9. Emergency services. Defined, §33-20A-3. Requirements, §33-20A-9. Experimental treatment. Patient’s right to independent review. Determining whether treatment is experimental, §33-20A-40. Financial incentive pro…
O.C.G.A. § 33-20A-7.1 Defined, §33-20A-3
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Payment of benefits, §33-20A-62. Quality assurance program. Requirements, §33-20A-5. Records. Patient records. Confidentiality and accuracy, §33-20A-8. Retroactive denial of claims, §33-20A-62. Defined, §33-20A-60.
O.C.G.A. § 33-20A-70 Insurance
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Group insurance. Authorized, §33-24-34. Deduction of premiums from wages or salaries, §33-24-34. Effect upon rights under workers’ compensation act, §33-24-36. Participation by employees generally, §33-24-35. Withdrawal or retirement from group plan, §33-24-35. Wages. Group insur…
O.C.G.A. § 33-20A-8 Confidentiality and accuracy of patient records
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Each managed care plan shall establish procedures to safeguard the privacy of individually identifiable patient information and to maintain accurate and timely records for patients. History. — Code 1981, § 33-20A-8, enacted by Ga. L. 1996, p. 485, § 1; Ga. L. 1999, p. 350, § 2. 33…
O.C.G.A. § 33-20A-9 Emergency services requirements; restrictive formulary requirements
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Every managed care plan shall include provisions that: (1)(A) In the event that a patient seeks emergency services and if necessary in the opinion of the emergency health care provider 803 33-20A-9 responsible for the patient’s emergency care and treatment and warranted by his or…
O.C.G.A. § 33-20A-9.1 Consumer driven health plan
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Health care spending accounts and consumer driven health plans, §33-30B-3. Consumer insurance premium finance agreement. Service charges, §33-22-9. 1129 INDEX DEFINED TERMS —Cont’d Consumer report. Insurance information, §33-39-3. Consumer reporting agency. Insurance information, …
O.C.G.A. § 33-20B-1 Short title
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This chapter shall be known and may be cited as the ‘‘Essential Rural Health Care Provider Access Act.’’ History. — Code 1981, § 33-20B-1, enacted by Ga. L. 1998, p. 900, § 2.
O.C.G.A. § 33-20B-2 Definitions
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As used in this chapter, the term: (1) ‘‘Essential rural health care provider’’ means any hospital, federally qualified health center, or rural health clinic, as such terms are defined in this Code section, which is located in a rural area and which complies with the provisions of …
O.C.G.A. § 33-20B-3 Short title
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Definitions. Qualifications for participating providers; reasonable consideration. 33-20B-3.1. Health maintenance organizations’ expansion into rural areas. Editor’s notes. — Ga. L. 1998, p. 900, § 1, not codified by the General Assembly, provides that: ‘‘It is the intent of the Gen…
O.C.G.A. § 33-20B-4 Termination as a participating provider
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To deny, reject, or terminate an essential rural health care provider from serving as a participating provider in a health benefit plan, the health care insurer shall: (1) Inform the essential rural health care provider in writing of the basis for such rejection or termination, in…
O.C.G.A. § 33-20B-5 Hearing and appeal rights of denied providers
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Any essential rural health care provider which is denied, rejected, or terminated from serving as a participating provider in a health benefit plan shall have the right of hearing and appeal before the Commissioner, or his or her designee, if that provider believes there has been …
O.C.G.A. § 33-20B-6 Definitions, §33-20B-2
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Health maintenance organizations. Expansion into rural areas, §33-20B-3.1. Qualifications for participating providers. When health maintenance organization not required to comply, §33-20B-3. Hearings. Rights of denied providers, §33-20B-5. Participating providers. Consideration. A…
O.C.G.A. § 33-20C-1 Definitions
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As used in this chapter, the term: (1) ‘‘Covered person’’ means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. (2) ‘‘Facility’’ means an institution providing physical, mental, or behavioral health care services or a healthcare se…
O.C.G.A. § 33-20C-3 Searchable format, §33-20C-4
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Update frequency, §33-20C-2. 1167 INDEX HEALTH INSURANCE —Cont’d Actual charge or actual fee. Defined in relation to specified disease insurance policies, §33-24-16.1. Adopted children. Coverage, §33-24-22. Group health plans, §33-24-55. Advertising. Accurate provider directories. …
O.C.G.A. § 33-20C-4 Notices to providers, §33-20C-3
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Posting online by insurer, §33-20C-2. Print copy on request, §§33-20C-2, 33-20C-5. Reliance on directory by covered person, remedies, §33-20C-3. Reporting by insurer, §33-20C-3. Reporting of inaccurate information, §33-20C-3. Searchable format, §33-20C-4.
O.C.G.A. § 33-20C-5 Printed directories; accuracy; application to standalone dental plans
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(a) The insurer shall make available in print, upon request, the following provider directory information for the applicable network plan: (1) For healthcare professionals: (A) Name; (B) Contact information; (C) Participating office location or locations; (D) Specialty, if applic…
O.C.G.A. § 33-20D-1 Definitions
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As used in this chapter, the term: (1) ‘‘Affiliate’’ means an entity owned or controlled, either directly or through a parent or subsidiary entity, by a contracting entity that accesses the rates, terms, or conditions of health care services. (2) ‘‘Contracting entity’’ means any …
O.C.G.A. § 33-20D-3 Prohibited activities; confidentiality agreements
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(a) A rental preferred provider network shall not: (1) Knowingly access or utilize a network provider’s contractual discount pursuant to a provider network contract without a contractual relationship with the network provider, rental preferred provider network, or third party; or…
O.C.G.A. § 33-20D-4 Rights and responsibilities imposed on third parties
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(a) A third party, having itself been granted access to a network provider’s health care services and contractual discounts pursuant to a provider network contract, that subsequently grants access to another third party shall be obligated to comply with the rights and responsibil…
O.C.G.A. § 33-20D-5 Exclusions
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This chapter shall not apply to: (1) Provider network contracts for services provided to Medicaid, medicare, the state health benefit plan under Article 1 of Chapter 18 of Title 45, or State Children’s Health Insurance Program (SCHIP) beneficiaries; (2) Employers, church plans, or …
O.C.G.A. § 33-20D-6 Penalties
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Any person or entity that is not duly licensed or that should be licensed by the department or that is not duly registered or that should be registered with the department pursuant to Code Section 33-20D-2 and acts as a rental preferred provider network, as defined in paragraph (7…
O.C.G.A. § 33-20E-1 Short title
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This chapter shall be known and may be cited as the ‘‘Surprise Billing Consumer Protection Act.’’ History. — Code 1981, § 33-20E-1, enacted by Ga. L. 2020, p. 210, § 1/HB 888. 33-20E-2. Application to insurers; definitions.
O.C.G.A. § 33-20E-10 Dismissal or arbitration requests
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The Commissioner shall dismiss certain requests for arbitration if the disputed claim is: (1) Related to a healthcare plan that is not regulated by the state; (2) The basis for an action pending in state or federal court at the time of the request for arbitration; 852 33-20E-12 (…
O.C.G.A. § 33-20E-12 Regulation; contracting with resolution organizations
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The Commissioner shall promulgate rules implementing an arbitration process requiring the Commissioner to select one or more resolution organizations to arbitrate certain claim disputes between insurers and out-of-network providers or facilities. Prior to proceeding with such arb…
O.C.G.A. § 33-20E-13 Selection of arbitrator
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Upon the Commissioner’s referral of a dispute to a resolution organization, the parties shall have five days to select an arbitrator by mutual agreement. If the parties have not notified the resolution organization of their mutual selection before the fifth day, the resolution organ…
O.C.G.A. § 33-20E-14 Submission of final offers; supporting documentation
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The parties shall have ten days after the selection of the arbitrator to submit in writing to the resolution organization each party’s final offer and each party’s argument in support of such offer. The parties’ initial arguments shall be limited to written form and shall consist …
O.C.G.A. § 33-20E-15 Proposed payment amounts
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Each party shall submit one proposed payment amount to the arbitrator. The arbitrator shall pick one of the two amounts submitted and shall reveal that amount in the arbitrator’s final decision. The 854 33-20E-17 arbitrator may not modify such selected amount. In making such a dec…
O.C.G.A. § 33-20E-16 Payment of expenses and fees
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The party whose final offer amount is not selected by the arbitrator shall pay the amount of the verdict, the arbitrator’s expenses and fees, and any other fees assessed by the resolution organization, directly to such resolution organization. In the event of default, the defaulti…
O.C.G.A. § 33-20E-17 Referral of parties for violations
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Following the resolution of arbitration, the Commissioner may refer the decision of the arbitrator to the appropriate state agency or the governing entity with governing authority over such provider or facility if the Commissioner concludes that a provider or facility has either …
O.C.G.A. § 33-20E-18 Limitation on litigation when arbitration sought
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Once a request for arbitration has been filed with the Commissioner by a provider or facility under this chapter, neither such provider nor such facility nor the insurer in such dispute shall file a lawsuit in court regarding the same out-of-network claim. History. — Code 1981, § 3…
O.C.G.A. § 33-20E-19 Resolution organizations
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Contracting with, §33-20E-12. Quarterly reporting, §33-20E-19. Rules and regulations, §33-20E-12. Selection of arbitrator, §33-20E-13. Submission of data by insurer to commissioner prior to referral of dispute, §33-20E-11. Balance billing. Denying or restricting benefits based on …